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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. 1 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. 2 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 3 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 4 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 2 3 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 5 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. 4 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. 6