Download The Medical University of South Carolina

An Academic-Community Partnership: The MUSC College of Nursing and
REACH Charleston and Georgetown Diabetes Coalition, South Carolina as
Integrators
What follows is the third part in a series of pieces that (1) document place-based approaches to
population health that strive to achieve the Triple Aim; (2) broadly describe the roles and
functions of an integrator; and (3) provide specific, on-the-ground examples of integrator roles
and functions. The examples illustrate specific integrator roles and functions performed the
Medical University of South Carolina (MUSC) College of Nursing and the Racial and Ethnic
Approaches to Community Health (REACH) Charleston and Georgetown Diabetes Coalition.
The examples do not exhibit the totality of each integrator function referenced but rather provide
a flavor for how each function could be performed in the real world.1
Introduction
Building on many years of work with the African American community in Charleston, the
Medical University of South Carolina (MUSC) College of Nursing convened a broad array of
community organizations to create a coalition that could compete for a Centers for Disease
Control and Prevention (CDC) Racial and Ethnic Approaches to Community Health (REACH)
grant when the program was first initiated in 1998. The goal was to ultimately eliminate racial
and ethnic disparities in diabetes, improve primary and secondary prevention and reduce lowerextremity amputations. The REACH Charleston and Georgetown Diabetes Coalition was
successful in its application and has been funded continuously by the CDC since 1999.
Over the past decade, the College of Nursing and the REACH Coalition have worked together to
perform the key roles and functions of an integrator. They have formed a true communityacademic partnership using principles of “community-based participatory action science.” Each
plays the integrator role, depending upon the function to be served or emphasis of the specific
initiative, and often both are involved to fulfill the array of functions required.
The College of Nursing provides the administrative base for the REACH grant and the Coalition,
employs Coalition staff, and fosters connections with the College of Medicine and other MUSC
academic entities. College of Nursing faculty bring the research and clinical expertise that
competed successfully for the initial and ongoing CDC grant awards, and College faculty
continue to pursue and receive other grant funding essential for initiating and sustaining
Please see “Integrator Roles and Functions” for a complete description of the roles and functions referenced in this
document. Please see “Transforming Population Health: Case Studies of Place-Based Approaches, REACH
Charleston and Georgetown Diabetes Coalition, South Carolina” for a more in-depth description of key population
health initiatives spearheaded by MUSC and REACH.
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numerous Coalition efforts. The College of Nursing also is the principal link to the South
Carolina Department of Health and Environmental Control (DHEC), which is the primary source
of data and analysis used to identify and prioritize issues and to monitor progress. For the past
four years, some REACH funding has supported analysis by DHEC staff. DHEC’s close
working relationship with the College of Nursing and the REACH Coalition leverages resources
and avoids duplication of effort, a key integrator function.
The REACH Coalition convenes and engages numerous community organizations and
volunteers and links to professional associations and state policymakers, though the Coalition
does not lobby. It addresses four key dimensions that interact to produce improved communitywide quality of care and health outcomes and elimination of health disparities: informed,
activated persons; prepared, proactive health systems; prepared, proactive community systems;
and social, health, and economic policies and actions. The examples that follow illustrate the
interrelationship of two entities serving as integrators in a particular geographic area to impact all
of the dimensions described above.
Developing a New Model to Reduce Admissions and Readmissions and Improve Care
Transitions for Patients with Diabetes
Integrator Functions 4 (assessing community resources and working to fill gaps), 6 (spreading
what works), 8 (leveraging existing and new sources of funding), 9 (gathering, integrating or
sharing data across the systems serving the population), 10 (connecting with system navigators),
and 11 (developing a system of ongoing communication and feedback at multiple community
levels)
An effort underway for almost a decade illustrates the academic-community partnership between
the College of Nursing and the REACH Coalition and the roles of these two entities as
integrators, serving complementary functions and continuously building upon the partnership to
create new opportunities for advancing clinical and community practice and bringing new
resources to support these efforts.
The integrators in this initiative consistently serve the important role of assessing community
resources and working to fill gaps. This is accomplished by a combination of communicating
directly with the community and gathering and analyzing the data available. From the early days
of the Coalition, REACH trained and employed Community Health Workers (CHWs) to serve as
system navigators and help to provide ongoing communication and feedback at multiple levels of
the community. During their direct interactions with community members, CHWs observed that
African Americans with diabetes had high rates of hospitalization and readmissions. In 2003,
data from the South Carolina Department of Health and Environmental Control (DHEC)
confirmed that African Americans had diabetes hospitalization rates more than twice as high as
whites: age-adjusted rates for African Americans were about 3,700/100,000 population,
compared to 1,800/100,000 population for whites. It was not possible to determine the rate of
readmissions as data were not captured in a way that could support this analysis. To address this
disparity, in 2004, the Coalition designed a feasibility study to test a new model of inpatient care
and hospital discharge follow-up that would link the inpatient and community settings.
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To advance this initiative, the College of Nursing played the key integrator role of leveraging
new and existing sources of funding, enlisted the MUSC hospital to be the test site for the
inpatient component of the new model, and secured salary support from the hospital for a nurse
previously with REACH to lead the inpatient program. The College of Nursing and an
endocrinologist from the College of Medicine, who receives partial salary support from REACH,
developed the clinical protocol in collaboration with Coalition members. To gain further insights
into the sources of admissions and readmissions, College of Nursing faculty secured a grant from
the National Institute of Nursing Research at the NIH from 2006 – 2009 to gather data at the
individual level by studying patients seeking care in the MUSC hospital emergency department.
This facilitated continued learning and innovation, an important integrator role.
For the community component of this new model, the REACH Coalition expanded the role of
the Community Health Workers to create “patient navigators” who could help link people with
diabetes discharged from the hospital to Coalition partners in the community. This included
linkages to Federally Qualified Health Centers (FQHCs) to provide primary care, as well as
linkages to social service agencies to provide homemaker services, housing, financial assistance,
and the array of other resources patients needed to manage diabetes effectively and avoid
hospitalization. To spread the navigator service to more patients, the Tri-County Black Nurses
Association, a key partner in the REACH Coalition, recruited and trained community volunteers
from approximately 40 churches to serve some of the tasks performed by the navigators, such as
completing forms to obtain prescription drug assistance. The CHWs developed a resource
manual for the volunteers to provide key information on community services, such as phone
numbers and hours of operation. The CHWs and volunteers also helped to “spread what works”
by offering educational programs about diabetes to the larger church community, using
educational materials and methods developed by the College.
With a new care model in place and several hundred patients participating to date, it became
important to evaluate the effectiveness of the model. However, it has not yet been possible to
perform an assessment because CDC funding for REACH does not allow collection and analysis
of individually identified patient data. Continuing the integrator role, in 2012 faculty from the
College of Nursing and the College of Medicine addressed this gap by applying for an NIH grant
now under review to support a randomized controlled trial that will test this new “care
transitions model” specifically designed for patients with diabetes.
The interplay between the College of Nursing and the Coalition as integrators has identified an
important community health problem; developed a promising care model to address it that
includes the use of system navigators; secured funding from a number of sources to implement
it; spread it to the community; and finally sought funding to rigorously test the clinical outcomes
of the model, highlighting the array of important functions integrators perform and the impact
they can achieve.
Creating and Disseminating “South Carolina Guidelines for Diabetes Care” 2011
Integrator Functions 2 (serving as a trusted leader), 4 (assessing community resources and
working to fill gaps), 5 – 7 (making and sustaining systems-level policy and practice changes
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and spreading what works at the policy and practice level), and 8 (leveraging existing and new
sources of funding)
Prior to 2011, no uniform set of guidelines was available in South Carolina for the diagnosis and
management of diabetes. Instead, multiple guidelines from various professional societies, the
American Diabetes Association and other sources were in use.
Recognizing this gap, the College of Nursing and the REACH Coalition worked to address it
through systems change, a key integrator role. Faculty from the College of Nursing and the
College of Medicine led efforts to synthesize more than 300 pages of different guidelines into a
two-page document draft and then worked through the REACH Coalition to finalize and adopt
the guidelines and share them widely to impact and sustain practice change.
The College of Nursing and REACH enlisted the Diabetes Advisory Council (a statewide
advisory group for REACH and the South Carolina Department of Health and Environmental
Control (DHEC) Diabetes Prevention and Control Program) and the Diabetes Initiative to work
together with REACH to finalize and adopt the guidelines that were officially released by the
MUSC President in September 2011. The College of Nursing and the College of Medicine are
trusted resources in the community for medical information, and guidelines published under their
auspices are trusted by physicians and other members of the medical community. This trusted
status enables the integrators to continue to sustain integrator functions over time, in this case
spreading clinical practice change throughout the community.
Specifically, to “spread what works,” the REACH Coalition and partners are now leading efforts
to translate and disseminate these Guidelines. Because of its educational and outreach expertise,
the Coalition supported development of a video and other training materials that have been
integrated into the curriculum for medical students, nursing students, advanced practice nurses,
and physician assistants. The changes in curricula enable the clinical practice changes to become
sustained over time, a key contribution of an integrator.
To further advance this work, REACH performed another important integrator function leveraging new sources of funding. With additional funding that it applied for and received
through the Community Transformation Grant that CDC awarded to the National REACH
Coalition, the local REACH Coalition is working with primary care offices to integrate the
Guidelines into ongoing care for diabetes. The Coalition is also disseminating the Guidelines
through its participating Federally Qualified Health Centers (FQHCs). In addition, the Coalition
is using the Diabetes Initiative’s Annual Primary Care Symposium and DHEC’s Annual Winter
Symposium as opportunities to offer continuing education on the new Guidelines, another way to
embed and sustain practice change. The Guidelines are widely disseminated on the websites of
the Coalition, the Diabetes Initiative and the SC DHEC. The Coalition is monitoring adherence
to these Guidelines and changes being achieved in diabetes control and is providing feedback to
community clinics and primary care practices, thereby continuing the communications loop to
the community.
Thus, because of their trusted status in the community, the integrators were able to fill a gap
related to a lack of uniform clinical guidelines for diabetes, address the gap by synthesizing the
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various existing guidelines and working with key partners to finalize and adopt new ones, and
ultimately leverage financial resources to spread the new guidelines through the community to
embed and sustain clinical practice change, all important integrator roles and functions.
Obtaining Insurance Coverage for Diabetes Care and Education
Integrator Functions 1 (engaging multi-sector partners), 3 (facilitating agreement among multisector stakeholders on shared goals), 4 (assessing community resources and working to fill gaps),
5 – 7 (making and sustaining systems-level policy and practice changes and spreading what
works at the policy and practice level), and 8 (leveraging existing and new sources of funding)
The following initiative exhibits how an integrator, in this case the REACH Coalition, can play a
meaningful role without leading all stages of the work. It shows the importance of integrators
engaging with multi-sector partners to achieve shared goals, in this case securing insurance
coverage for diabetes care and education in South Carolina.
A community assessment among patients with diabetes and their families conducted by the
College of Nursing in the earliest days of the REACH Coalition identified a major financial
barrier to effective diabetes care—insurance did not cover the cost of many supplies essential to
a patient’s management of diabetes and also did not pay a physician for providing education on
diabetes self-management. As a result of this barrier, the REACH Coalition engaged with
partners from other sectors to pursue systems-level changes. In this case, the integrator was able
to work through a key partner, the American Diabetes Association, to create the necessary policy
change, and then the REACH Coalition played a critical role in the spread and implementation of
the change. Through this initiative, the REACH Coalition served a key leadership role by
intentionally spending energy and offering credibility and expertise to the area of financial
sustainability, an important integrator function.
A multi-sector partnership led by the American Diabetes Association and supported with
information on evidence-based educational programs provided by the REACH Coalition and the
Diabetes Initiative approached and worked with interested legislators to fill the gap identified in
the community assessment. They developed legislation that would improve insurance coverage
for diabetes supplies and equipment for diabetes self-management as well as provide payment to
physicians who offered diabetes self management education (DSME).2 In 2000, the partners
succeeded, and South Carolina Code of Laws Section 38-71-46 established the requirement for
coverage of equipment, supplies and medications for diabetes in all health insurance policies
(except for ERISA exempt plans).3 Coverage was also established for diabetes self-management
education for all insurance plans (except ERISA- exempt (self insured) plans), including South
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Of note, the REACH Coalition did not participate in lobbying the state legislature.
SECTION 38-71-46: Diabetes Mellitus coverage in health insurance policies; diabetes education.
(A) On or after January 1, 2000, every health maintenance organization, individual and group health insurance
policy, or contract issued or renewed in this State must provide coverage for the equipment, supplies, Food and
Drug Administration-approved medication indicated for the treatment of diabetes, and outpatient self-management
training and education for the treatment of people with diabetes mellitus, if medically necessary, and prescribed
by a health care professional who is legally authorized to prescribe such items and who demonstrates adherence to
minimum standards of care for diabetes mellitus as adopted and published by the Diabetes Initiative of South
Carolina. Source: http://doi.sc.gov/Documents/laws/t38c071.pdf
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Carolina Medicaid4, an important systems change that helped to improve financing of health care
for people with diabetes.
After passage of the legislation, the REACH Coalition recognized the need for systemic change
in policy to be supported by practice change, as integrators look at the whole system and
determine how systems must work together to support the needs of a patient or individual.
Specifically, the REACH Coalition worked with several Federally Qualified Health Centers
(FQHCs) and the largest network of primary care providers to develop American Association of
Diabetes Educators-accredited diabetes self-management education programs that would qualify
for reimbursement from Medicare, Medicaid and private insurance. The Coalition also provided
training on diabetes self-management that primary care providers have used as part of their
certification to become Patient-Centered Medical Homes. These practice changes were critical
complements to the policy change.
As the integrator, the REACH Coalition has thus covered the spectrum from problem
identification to working through multi-sector partners to advance policy change to achieve
shared goals to ultimately providing the education and technical assistance that enable practices
to benefit from the statewide systems changes in reimbursement policy.
Sources
Nemours developed these case studies to provide examples of population health innovation in the
field and to demonstrate the work of integrators on the ground. This case study was prepared by
Julianne R. Howell, PhD, Daniella Gratale, MA, Allison Gertel-Rosenberg, MS and Debbie I.
Chang, MPH, using the following sources, and was issued in October, 2012:
1. Telephone conversations with Carolyn Jenkins, DrPH, APRN-BCADM, RD, LD, FAAN,
Professor and Ann Darlington Edwards Endowed Chair, Principal Investigator for
REACH 2010 and REACH U.S. Charleston and Georgetown Diabetes Coalition, College
of Nursing, Medical University of South Carolina, Charleston, South Carolina.
2. “Integrator Role and Functions in Population Health Improvement Initiatives.” Prepared
by Nemours with input from national and community health experts, health providers,
health plans and other partners. May 2, 2012.
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Codes G0108 for 60 minutes of individual education and G0109 for 60 minutes of group education were
established. Reimbursement rates in 2011 were $55.41 for G0108 and $32.62 for G0109.
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