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Rio Grande Valley Chronic Care Management Coalition
Belinda Reininger, DrPH
Rio Grande Valley Chronic Care Management Coalition Belinda - - PowerPoint PPT Presentation
Rio Grande Valley Chronic Care Management Coalition Belinda - - PowerPoint PPT Presentation
Rio Grande Valley Chronic Care Management Coalition Belinda Reininger, DrPH Collaborative Project Implemented Across the RGV Implemented Across the RGV Upper Valley Project Lower Valley Project Salud y Vida Serves Participants with
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Implemented Across the RGV
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Implemented Across the RGV
Upper Valley Project Lower Valley Project
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Salud y Vida Serves Participants with Uncontrolled Diabetes each Demonstration Year
1205 1755 1204 1205 2670 2626
500 1000 1500 2000 2500 3000 DY 3 DY 4 DY 5
Individuals Receiving Chronic Care Managment Services
New Enrollment Total Served
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Majority of Salud y Vida participants are improving control of diabetes
Includes data from October 1, 2013 - February 1, 2016 1665 1343 1072 866 325 621 603 496 381 200 200 400 600 800 1000 1200 1400 1600 1800 3-MONTHS 6-MONTHS 9-MONTHS 12-MONTHS 15-MONTHS Total Participants
Comparison of Baseline and Quartery HbA1c Results
Reduced HbA1c Increased HbA1c 69% Success 68% Success 69% Success 73% Success 62% Success
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10.12% 9.08% 9.22% 9.28% 9.42% 9.97%
8.40% 8.60% 8.80% 9.00% 9.20% 9.40% 9.60% 9.80% 10.00% 10.20% Baseline 3-Months 6-Months 9-Months 12-Months 15-Months HbA1c
Average HbA1c Results
Average HbA1c values improve during the time frame where program services are most concentrated
Test Completed 3345 2286 1946 1568 239 525 Tests Missing 833 940 933 720 999
Includes data from October 1, 2013 - February 1, 2016
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- Attend DSME classes
- Assigned community
health worker (CHW)
- If no PCP, connected
to a Medical Home by CHW
- Receive home visit
and assessments by CHW
- Receive motivational
text-messages
- Receive HbA1c test every 3 months
- Receive support via phone & home visits from
CHWs
- Attend Participant Advocate Leader Board
meetings
- For participants with HbA1c results increasing 1.5%
- r greater, receive case review with action plan
- Obtain care coordination between program and
medical home
Day 1 for participants
- Enroll in program
- Receive
evaluation
- Enroll in Diabetes
Self- Management Education (DSME) course
Months 1 – 2 for participants Months 3 – 12 for participants
Salud y Vida Program Services Time Line
Receive referral to other resources e.g. behavioral health, exercise and cooking classes, Compassion Funds, transportation assistance, social worker services, support groups
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Improved HbA1c Control
Community Health Worker (CHW) home visits CHWs and nurses coordinating visits with medical home at clinics Nurses relaying important health information to clinics CBOs Providing Diabetes Self- Management Education in clinic and community Behavioral health screening and services provided by mental health authority Social Services provided by clinics, CBOs, hospitals
Coordinated Care Across Partner Organizations
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10.4 7 6.9 6.9 6.4 2 4 6 8 10 12
Meet a Salud y Vida Participant * Name changed
Before Salud y Vida Ms. Cruz* was at high risk
- 53-year old with Type 2 diabetes
- HbA1c > 10.4% at time of enrollment
Salud y Vida Team
- Enrolled the participant in Diabetes Self-Management
Classes (DSME) and completed all classes prior to the 3- month time point
- Worked together to improve eating habits
- Provided glucometer for daily monitoring
- Provided 7 home visits and multiple phone calls
Better Health!
- Stabilized glucose levels
- Changed eating and exercise habits
- HbA1c decreased after 12 months
- Volunteered as peer facilitator with support groups
“I always thought that visiting your physician and taking your medications was all you needed to do. In Salud y Vida I have learned a lot… I was the kind of person that by eleven in the morning, I was sleepy again. No strength, didn’t want to do anything. Now I have lots of
- energy. I believe it’s never too late to start. I’m 53 years
- ld and I feel great, something I could have said in those
12 years I lost.” HbA1c Results
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Salud y Vida, a program delivered through a coalition model will serve by end of DY 5 at least 4,164 individuals with uncontrolled diabetes in the Rio Grande Valley over 3 years.
77% will attend at least 1 Diabetes Self-Management Education class and 68% will complete all classes 68% of those that receive an HbA1c test will reduce their HbA1c within 3-months 66% will have reduced their HbA1c at 12-months. 41% will reduce their HbA1c below 9 at 12-months.