Good morning, everyone. I'd like to start on time. It's 10.30 already. Nice to see your faces here. Welcome to this session on Innovative Systems Approaches to Achieving Health Equity in Diabetes Prevention. My name is Dr. Liana Leonoff, and I am the medical faculty and consultant with ACPM on this project. And this project is part of a CDC grant and that I'll be sharing a little bit more about. We don't have any disclosures. Myself and all of the speakers, you'll be hearing from several of us. Very briefly, what we're going to be doing is I'm going to just spend about five minutes giving you a little background and project overview, and then I'm going to turn it over to our partners at the American Medical Association to give you a little overview on clinical engagement and the results from our project sites. And then to our representative from the Black Women's Health Imperative on social determinants of health and how that relates to our national DPP. We'll also have the pleasure to hear from all three project sites. And then the main thing is for us to really engage and have an open discussion about what's working and what's not working. So the bulk of the session will be in three breakouts, and we'll figure out the logistics because we had hoped for some roundtables, but we'll figure that out. We'll roll with it here. So the learning objectives for this session are to articulate two evidence-based strategies to screen and test disproportionately affected populations, and then refer those patients with prediabetes into the National Diabetes Prevention Program, to list at least two high-touch coaching tactics and tools for enrolling and engaging patients into the program, and to describe at least one promising practice and or challenge for assessing and addressing social needs barriers of patients with prediabetes who are referred into this year-long program. Again, this is part of a CDC cooperative agreement. It's a large agreement with several elements. We are focusing on the first element that's highlighted there, which is building provider capacity to screen, test, and refer disparate populations with prediabetes. It's a multi-year initiative that supports the implementation of innovative health system and community-based approaches to address and improve diabetes prevention in marginalized populations. And we selected our grantees through an RFP process, and we've been providing ongoing technical assistance through the ACPM partnership with the American Medical Association and the Black Women's Health Imperative. The goals of this project are fourfold. Number one, to increase screening and testing of patients in the target populations that are at high risk for prediabetes and refer them into the CDC-recognized diabetes prevention program, to engage patients from the target populations and get them enrolled in the program, and most importantly, to really help our CDC-recognized organizations to retain the participants for the duration of the program. Again, it's a year-long program. Number three is to address those social determinants of health, at least one major social determinant of health that's identified as a barrier for enrollment and engagement in the program. And last but not least, to collect and report data on the process and outcome measures that reflect the experiences of our target populations that reflect the experiences of our target population, as well as the impact on these populations from the kinds of interventions that we've been providing. So here are our project partners. From the American College of Preventive Medicine side, there's myself. There's Anita Ballin, who's been the backbone of this project, who's unable to join us today. Thank you, Anita. And these slides, even though they have my name on them, are really Anita and the whole team. So thank you, team, as well as Kate Shreve from ACPM. And then on the AMA side, we have Janet Williams, who's the senior program manager, as well as Maddie Brady, whom I'll be introducing shortly, Shannon Haffey, and Temkin Khan. And they've all been working very hard on this project. And last but not least, the Black Women's Health Imperative with Kimberly Lovelady, whom I'll be introducing, as well as Paula Green-Smith. OK. Hang on. So our first speaker is our first. I'm going to spend a minute introducing two speakers from the partnerships. Then they'll present. And then I'll come back up here and introduce our three grantees. And they'll each have a few moments. So our first two speakers are Maddie Brady. She's the project manager in the Improving Health Outcomes Department at the AMA. And she's also on the Ecosystem Change Team that's focused on removing barriers to cardiovascular disease prevention. And she's a lead project manager on this initiative within the AMA. And then she'll be followed by Kimberly Lovelady, who is a senior program manager at Black Women's Health Initiative. And she's providing technical assistance and training to improve health of black women and girls. And she's also a master trainer within the National Diabetes Prevention Program, among many other ways that she's helping underserved. Thank you. We were working with the clinical teams to create system changes, little changes in these health systems, electronic medical records that could really make a big impact when it comes to their diabetes prevention strategies. You guys will have the opportunity to hear more specifically about these in greater detail. And if you hear anything, remember it, so you can ask when we're going into the breakouts. But all three grantees did an excellent job at making system-based changes and to highlight a few, there were care pathways created specifically for pre-diabetes. There were standing lab orders created so anyone who was eligible to be tested for pre-diabetes got that standing lab order. There were clinical decision algorithms, BPA alerts, pre-diabetes registries, so they would have a list of patients that were at that level that they could go through. And then one grantee site even leveraged text messaging to their patients to remind them of screening and for also recruitment to the national DPP. The next big thing we worked on was care team engagement. So now that we've made these changes and we've done this work, how do we really get the buy-in from the clinical team? How do we get people to actually use some of these changes that were done? And what we realized quickly was constant, constant reminders from various different mediums was really necessary, because we all know providers have many competing priorities and pre-diabetes isn't always at the top of that list. So we really got the help of provider champions who could champion this work with their clinical teams. And this included having presentations at different meetings such as grand rounds, clinical meetings, committee meetings. We found even asking for five minutes on an agenda would oftentimes give you that time you need to just reinforce what we're doing, how you can make these changes, screenshots from the electronic medical record that show what you're trying to do. One grantee did a quality improvement project of a PDSA cycle specifically on pre-diabetes. So the next two slides I am presenting on behalf of my colleague, Dr. Khan, who had a last minute hiccup and couldn't make it. She apologizes. She helped us as a senior economist and helped us really with all of our data. So I will do the best here. But if you look at this first or second column, the first column of numbers on the left-hand side, that is a cascade model that was created by Dr. Khan based on various data sources, Ed Hinds, among others. But it's really looking at what you expect from the US population. The next two columns, the middle column and the one to the right, is data specifically from these pilot sites. So the middle column is a total of the pilot sites and the column to the right is the population of black and Hispanic women, which this grant was specifically looking at. So I would like to call out some very great improvements that we saw that we were excited about. So starting with the screening numbers, you can see that these pilot sites did much better than you would expect from the average US-level cascade. Also, with the patients willing to participate, they did much higher. And then lastly, with the referral counts, you can see all of that work paid off and that the referral counts are almost three, four times what you would expect with the US-level cascade. And at the bottom, we have the enrollment, which is still something that we're working on that anyone in this space will tell you is the hardest piece of the puzzle. But what you can really see from all of this is it is working. Screening and referrals increase from all of this great work. And with that, I'm gonna hand it to my colleague, Kimberly. Thank you. Okay, good morning, everyone. There we go. I was like, no feedback, because I'm very interactive. Okay, so I'll start with, my name really is Love Lady. So we can get that out the way. You can get that out of your mind and we can go. I'm with the Black Women's Health Imperative. And what we do, our mission, and this year we're celebrating 40 years, is to actually help the nation's black women and girls. That is our mission. So we look at health equity. That's who we are, what we do. So everything that I say, most of the time I just think people get it, but I have to realize that's who we are, that's what we say, that's what we do. We do it for different levels, from cradle to the grave. So that's the area that we focus on. And these are some of the initiatives, like the diabetes agenda and everything. So that's why they pulled us in. And really the reason why they pulled us in was because doing a diabetes prevention program over since the 1212, we have created this thing called the High Touch Coaching Model, because we realized that when we were with CDC, we were like, everybody has all these wonderful numbers of everybody they're enrolling. Our numbers are not looking like that, but our success rate is looking amazing compared to everyone else. So it's like, what is the difference? So on this project, I focused on helping integrating the social determinants of health. So before I go there, I have to tell you a dirty little secret, right? I am a master gardener, right? That's my thing. I get excited about it. It makes me, I know I look like a gardener, right? But when I think about gardening and I think about the social determinants of health in the diabetes prevention program, it's like the soil and the climate conditions for a great garden, right? And just as the quality of soil and the sunlight and water influence the growth of the health of plants, the social factors like the income, the health literacy, the social connectiveness, right? The access to healthy food and physical activity opportunities and healthcare services that are equal and that are culturally competent, those things shape the outcomes of the diabetes prevention program, right? So we're going outside of the exam room. We have to, we worked on creating an environment that promoted so the women can attain their full potential for health and being for black women and Latinas. That was what, so think about a well-tinted garden, right? It has the rich soil, it has the sunlight, it has the watering, and it helps produce the healthy, thriving plants. Well, when we found that, we brought in a high-touch coaching model into this. It helped the hospital systems create environments that help the women grow and to even get to the programming. Now, AMA did an excellent job of working with the grantees to get the referrals going. It's like, okay, we have the referral going. But when we realize that we're working through the project, we have to integrate this at every step of the journey, from the marketing and the outreach down to the screening and referrals, I mean, to enrollment and program delivery, taking the lessons learned, the good, the bad, the ugly, as well as do continuous adjustments and keep going. Well, how did that look like, and what did it look like, and how do we do it? I'm gonna spend a lot of time on this slide. The technical assistance that we provided came in different forms. For outreach, maybe the hospital system was like, oh, we have this great marketing thing, but nobody's coming, right? And it's even in Spanish for the people who were working with Latinas, but no one's, out of 100 flyers we sent out, we got zero response back. Why, why is that? And so we were able to dive deep and look into it and say, okay, what does this marketing look like? I know you're, quote, unquote, excuse me, speaking the language, but are you really talking to the participants, the people that you're looking for? And it went from, the TA probably went from a page of lots of words to pictures that look like the people, that reflect the people, that actually evoked emotion, right, and taking the focus off of the hospital system and onto the person, because it's all about what's in it for me. Everyone who's in this thing is looking at what is in it for them. The participant, or the client, or the patient don't care about your diabetes prevention program. They care about how they can get better. Like, and how can I show up for my family, be here for my grandkids, be here for, and do all the things, right? We also, for each hospital system, conducted a SWOT analysis on the programming side so they can see what is our strength, weaknesses, opportunities, threats, and then they came up with a plan of things they could execute. And one of the things that we learned is that not only do you need a physician champion, you need an administrative champion, as well as a program champion. You need, because they are gonna be the people who go to bat every time someone says, we can't do that, this is not what we're gonna do, right? You need those three in your program. And then, you need someone there who asks the hard questions, because sometimes to get this program where you want it to go, you're gonna ask questions that nobody wants to answer, but it's the big elephant in the room that nobody's dealing with. Like, do you have all the right team members on the team? If we are going after black women and Latina, is that person reflected on this team? If that person's not reflected on the team, we gotta stop everything you're gonna do and at least go with someone that's at least an expert on it, or they need to be in the room. How can we have a program for someone and their voice is not even being heard? Because the participant voice is the most important voice in the room. That's one of the high-touch coaching things, okay? Culturally competent, culturally aware. I like to say culturally proficient. It's not just, we took this class and we're learning something, like, no, you're either all in or you're not. And if it's not you, that's fine. Someone on your team should be. It doesn't have to be you, but it has to be on your team. We did some things. We found out, especially after AMA showed you the referrals, we got it going. It's in their EPIC systems. And now, there's a little bottleneck, because the referrals are coming through, but the enrollment numbers are not there. What is the bottleneck? So we focused in on the bottleneck. And one of the things we found, yes, in the midst of COVID, like we all experienced, we realized that as much as the high-touch, we have high-touch, and high-touch coaching means that you're gonna do a lot of touches. There's a lot of physical touches in this project in order to get to that person. So if you think that this is a one and done, don't start the project. I know I'm not supposed to tell you that, but if you guys aren't willing to commit and put in the work, do not start it, because you're gonna be frustrated. And so with the high-touch coaching, but some of our partners let us know that high-touch coaching doesn't mean that you have to physically touch all the time. Some of the stuff is automated. The texting, the campaigns, the Zoom calls, the reminders, all that, we can automate, but you still have to do the touch. And so with the bottleneck, we found that you can't take the human touch out of the port between enrollment, referral. Between referral and enrollment, the organizations that had the best results had a human touch at that point. Someone picked up a phone, someone made sure they called. It was some kind of a human touch, and where that happened, the conversion rates increased. And then when we had to take that touch away, we watched the conversion rates decrease. So I'm like, if you have to skim on anything, don't skim on a human touch between enrollment and referral. Keep the human touch involved. And some of the things we also did was gamification. Guys, it's a year-long program. We get bored. Everybody gets bored. They're like, what is it that's gonna keep me engaged, involved? And so some of the organizations learned about incorporating gamification into their program. What does that look like? What to make it stick and make the people stay. And not only that, but we learned from the participants, what's gonna make you stick? What's gonna make you stay? Like, ask the hard questions. And the gamification also helped with the social connectedness of dealing with that piece of the puzzle, because once we did a lot of our key informant interviews, we realized that people were disconnected. And the program actually gave them, it built in a connective, and that's what helped them stick too. So, thank you. One of the things also, it was really important with the, and this is collaborative partnerships, once the doctor asked a question and they flipped a switch in the system that asked the SDOHs, okay, cool, sorry. Once they flip the switch, to make sure that within it, some of the systems are talking, you'll hear them talk about incorporating food programs, things that deal with food insecurity. Well, they had partnerships, and partnerships are key. And one of the things I'll even say, I'll even branch off to say is that within the partnerships of this, make sure they're real partnerships. Don't start a partnership just for the program. If you start a partnership just for the program, you need to grow and foster that partnership before bringing it to the community. Because people can tell when you're disconnected within that partnership, you know. And if, for some reason, your organization, and of course, none of you guys work at hospitals like this, that may be disconnected from the community, even though they service the community, you know, nobody's doing it. Make sure that the participants feel the sincerity, because they can smell insincere a mile away. And they'll let you know on certain terms, and even if it doesn't verbally come out, it'll come out with your numbers. And you're like, we got this wonderful thing, and nobody's coming. They feel the insincerity. So work on the partnerships. Because one of the projects, we had a hiccup with a major community partner. And you have to heal that relationship in order to be effective. So work with local businesses and stuff. And the health literacy, sprinkle the dust, okay. I like to really get in there and find out what is it that the population is looking for. Making sure that, if you can, I know resources are limited in some areas, but really make sure that the person who's delivering the program reflects the community you're servicing. That is so huge. And I know it seems like it's no big deal, but it really is a big deal. Because for that individual to see themselves in the person that's helping service them is really a big deal. And we'll go through a lot of this later on in the break-out session, guys, sometimes. We'll go through a lot of this in the break-out session, because I want to be respectful of your time and everyone else's time. And that's what I'll leave you with. Thank you. Thank you, Kimberly. She's just so passionate. I couldn't, even though we're over time, we had to hear your message, so thank you. And we'll have more time to discuss for sure. So now I have the pleasure of introducing our three grantee groups. So I'll introduce all three of them, and then they'll come up one after the other. So the first grantee is Northeast Valley Corporation. They refer to an internal National Diabetes Prevention Program. And we're going to hear from Debra Rosen, who's the Director of Quality, Health Equity and Innovation at Northeast Valley. And Northeast Valley is a non-profit, federally qualified community health center serving the underserved in L.A. County. And she's also overseeing their social determinants of health program and using Prepare and digitizing it to interface with the EMR and so much more. So we'll be hearing about that. And we'll also be hearing from Carolina Aguilar. She's the Program Manager of Health Education at Northeast Valley, and she oversees and promotes various programs, including the DPP, diabetes self-management, and much more. So that's our first grantee. Our second grantee is Parkland Health Systems, and they refer to a National DPP at Baylor Scott and White Health System. And so we're going to hear from Dr. Michael Bowen. He's an Associate Professor in the Department of Internal Medicine, Division of General Medicine, Department of Pediatrics, and the Peter O'Donnell School of Public Health at UT Southwestern Medical Center in Dallas. And his research focuses on harnessing the data from EHRs for scalable population health strategies to address diabetes. We'll also be hearing from Andrea Harris, who's the Director of Programs for Baylor Scott White and Health, Health and Wellness Center. And she's responsible for community outreach, membership, fitness, health and wellness, and so much more there. So that was our second grantees. And then our third grantee is Valley Medical Center in Seattle, Washington. They refer externally to community organizations, namely the YMCA of Greater Seattle. So we're going to hear from Dr. Kim Herner. She's worked at the center for 27 years. And she's their first Chief Quality Officer, focuses on integrating across acute and ambulatory care settings, care coordination, transitions management, and so much more. And last but not least, we'll also hear from Sally Sundar. She has worked for eight years in chronic disease prevention initiatives, first at the CDC and now at the YMCA of Greater Seattle. She oversees clinical integration, chronic disease prevention, programming across the YMCA's in King County and other YMCA's in the Washington State Alliance. So looking forward to hearing from all of you. So first up is Northeast Valley, Deborah Rosen. Good morning, everyone. I hope you can see the slide. So my name is Deborah Rosen, as nicely introduced, Director of Quality Health Equity and Innovation at Northeast Valley Health Corporation. So we are a federally qualified health center. We serve the underserved population. About 90% of our population is under 100% of the federal poverty level, and the rest is under 200%. So mostly Latinx, so about 80-85% of the population is Latinx. And we are in Los Angeles County. We're pretty large. We have 17 locations, clinics, and soon to have two more, ever growing. And we have over 300,000 visits a year, about 85,000 patients that we take care of. So very large, and we've been privileged to be a part of this program. So I was asked today only to have one slide. Let me tell you, that was not easy. We went over time last time, but they asked me to speak only five minutes, because I think the real discussion is in small groups, and you'll be able to ask questions and really engage. But what we did was we wanted to show you our approaches and interventions, and it starts with clinical decision support. So as you're well aware, there are so many things that the provider and care team need to do when that patient walks through the door, and that's not even talking about population health and outside of the visit. But once they walk through that door, or on a telephone, or telehealth these days, there's many things that we we need to do at point of care. And so what we did was we created an alert, as we do for many things that are due, but this was an alert through our clinical decision tools. And we have a population we use NextGen for our EHR. We have a population management tool called Ida iTrax, and through Ida iTrax, it pulls data identifying that the patient is at risk for diabetes or prediabetes, and it sends, it shows an alert in red so that the care team and provider know this patient is at risk. And with that, the next step is to screen that patient for diabetes. So that goes with the standing orders that you've heard a little bit about. So it doesn't have to be the provider, it can be the MA that places those orders in NextGen. And then based on the results of the order, if they're a diabetic, they go through the diabetic algorithm. If they're pre-diabetic, we created an algorithm for that. And that includes diagnosis in the medical record, that still doesn't always get there, of pre-diabetes, as well as brief counseling and then referral to the Diabetes Prevention Program. Those are submitted through our referral process within our organization, and then it goes to our department, overseen by Carolina. Those referrals are identified by the provider. So that's a really, there's lots of other ways that we reach out to patients, but as you can imagine, if your provider refers you, gives a strong referral for anything, it's more likely that the patient is going to be engaged. So that's a really important piece. But it doesn't end there, because our patients do, as you heard, it's not so easy to engage. It seems that our patients are much more interested in taking care of their children than themselves, and so this is a little bit harder. So we do outreach calls, we use text messages, but we use that live touch that you heard about to enroll those patients. And we have our own trained staff in the Diabetes Prevention Program who do speak the language, look like our patients, are culturally sensitive, live in in the area, and really are representative of those patients. And so we schedule them, and we do have frequently starting programs. It changed a lot, and we'll talk about that as we pivoted during COVID. So we've got different modalities that are all very effective, but the lifestyle coaches really, as I said, implement the program in various modalities, and so there's a lot of engagement, continual engagement there. So moving over to the right, successes and challenges. So the system changes is really what I started with, talking about identifying those who are at risk that haven't been screened. And we have those standing orders, as I mentioned, and we have algorithms of how to respond to those results. We've used very innovative strategies. We do screen our patients for social determinants of health. Actually, we do that through the lifestyle coaches do the screening, so they're very much connected to those patients and really help support them. And I'm gonna just comment on one thing about the social support, because it is, it was so astounding to me, it still is, that when we did, we used the prepare tool. Some of you, anyone familiar with the prepare tool? Just a couple hands. So that was produced or developed by the National Association of Community Health Centers, and so that's a standardized tool, and we've just scored it to actually risk stratify our patients in prepare, but I'm sidetracking, I won't do that too much. And with the prepare tool, we identify patients for many risk factors. So prior to COVID, we did not see social isolation very much. I mean, food insecurity, transportation, those were very high, and continue, and worried about losing housing, very, very high. After COVID, social isolation was the highest, and we were, I'm still astounded by that, surprised. And so having, you know, we just didn't even realize that through the Diabetes Prevention Program, that provides a support for one of the social determinants, which is so important. We also work with food insecurity, we'll get into that later, but having this small group of like-minded, like individuals, that they can not only relate to the coach, but to each other, really improve that social support. But last and not least, this is not easy. It is really challenging to sustain, in that there needs to be constant, not constant, but periodic, I should say, reminders to providers and to staff. We need to support the staff. Standing orders sound perfect, right? So easy. MAs can put them in, but if you have an MA that is not proactive, not comfortable putting in those orders, if the provider is not supporting that, then that's going to fall through. So all of these things, take oversight, sustain change, and retraining. And so we are, do have the privilege of being able to get into those provider meetings as frequently as we need. We get in there, we see those referrals going up, and then I'm getting the hook. So I look forward to more discussions. Good morning, everybody. Ah, you're getting better at this. See, Kim, you trained them. So I'm Michael Bowen from UT Southwestern and Parkland, and I'm partnering with Dr. Andrea Harris from Baylor Scott and White. And our program is different from some of the other ones you may hear about, in that we are two entirely different institutions within the same city. So we're located in Dallas County in Dallas, Texas. And I represent the Parkland side, which provided the referral aspect for this project. And then Dr. Harris represents the Baylor Scott and White side, which provided the delivery of the DPP program. And really quickly, just a little bit about Parkland to understand it. So Parkland is actually an integrated safety net health system. So in Texas, we did not expand Medicaid. Therefore, we have the highest uninsured rate in the country. And the system is actually designed as a payment plan to provide comprehensive care to patients. So inpatient, outpatient, specialty care, and primary care. And so as part of this, we have some ongoing initiatives focused around diabetes screening and prevention. And one of the things that we already knew at our institution was we screen a lot for diabetes. Our gap was actually getting them connected to programs to intervene. And so we tackled this in a couple of ways. So one is we just did a lot of public awareness and increased engagement at our local clinics. So we partnered with one clinic in our system. So there are 12 clinics scattered around Dallas County that provide comprehensive care. We partnered with one that was strategically close to Dr. Harris's program. So they're about a mile away. And we did that purposefully to try and limit some of the transportation challenges because many of these clinics are neighborhood based. And so first of all, we encouraged our PCPs to make referrals because prior to this program, we did not have a DPP opportunity because the health systems not provide one. So our default pathway was actually for nutrition. Secondly, we created a pre-diabetes registry, which basically captured a list of all patients in the health system that had a diagnosis of pre-diabetes using lab criteria because it was more reliable than counting on the diagnosis codes. And using that, prior to COVID, we actually had a medical assistant in our clinic who would go through and work this list. And this was perfect because she actually knew many of these patients. She knew them personally. She knew their family members. She had seen them in clinic. And she would actually pin the referral order for our providers to sign. And then we also partnered with our nutrition colleagues who, when they were seeing patients who were interested in having additional touches around diabetes prevention, the nutrition alone, would make those referrals. So we captured these referrals into Epic in a workaround that we had to create because our two systems are not connected. So we both operate on Epic, but they don't connect. And we can get into this a little bit more in the breakouts. But basically, we created a referral report that we captured and extracted. And then we actually secure transferred that file from the Parkland side using one of our staff members to the Baylor side, where the program coordinator there would then reach out to the patients and engage them. And one of the things that we really did to kind of also drum this up was we did quarterly reminders with our staff. So we fed back the referral reports to them. We put up clinic flyers. We had some challenges with recognition of our Parkland patients saying, well, why is the other health system at Baylor contacting me? Because I'm a Parkland patient. Because they identify with their system. So we actually did some tables in the clinic where the Baylor team actually came to the clinic, set up signage, flyers, met people, and did these things as well. And this really enhanced some of the uptake and collaboration there. So I'll turn it over to you, Dr. Harris. OK, so good morning. So Baylor Scott and White Health and Wellness Center was put in an area that is low socioeconomic status because the incidence of diabetes in that part of Dallas County is the highest. And so we have a diabetes prevention program or a program that our model, this circle of care, actually what we try to do is incorporate three main things. Because we have high incidence of diabetes, we also have a lot of other chronic illnesses. So these three things are, first of all, medical care. And in this particular program, that was actually coming from Parkland. We also have physical activity. So we have different physical activity programs. And then we have nutrition and education classes. So our diabetes prevention program is actually taught by community health workers. We have a community health worker training center. And the way that we actually try to connect with the community is that we go out into the community in the churches, which is extremely big in that particular part of Dallas, and we recruit people to come and work for us as peers. And we train them as community health workers. And then they're able to actually go and teach our classes in the churches and in the communities. So we have several different programs going across Dallas County. And our lifestyle coaches are actually able to get these different referrals for our diabetes prevention program. And we're able to connect with them. We have Farm Stand. We have other programs. And one of the reasons why we were actually successful is because we would go to Parkland Clinic, which is right around the street, and not just get them into the different diabetes prevention programs, but because we have several different cohorts, and we're kind of short as far as staffing. And we could only actually have classes at certain time periods. We would actually introduce them to some of the other programs. And so we would be able to actually get them to come to our cooking classes, or our nutrition classes, or our physical activity classes. And so when we were able to start our diabetes prevention program, they were more engaged. And I think when we started doing that, we were actually able to get more people. Good morning. I'm Kim Herner, and I'm at Valley Medical Center. As you heard, I've been there for quite some time. Valley Medical Center is located in Renton, Washington, which is sort of halfway. And we have a very diverse population in the state. And we also have a lot of big clinic system with about 14 primary care clinics. And we've found we're working with the YMCA and I'll let Sally talk a little bit about that. But we really have the same service area. And so one of the clinics that we really started working at was really just across the state. So, what you're looking at, the quadruple aim, we call this the quadruple aim in the context of clinic-to-community linkages, and this is something that our YMCA actually put together a few years ago in partnership with clinical partners to illustrate how we have the same goals. We're trying to improve individuals' health and well-being across the spectrum of what they see and value and define as their health, and we're doing that in a way that improves their health outcomes, but ideally is benefiting the health system as well by both managing and preventing costly conditions like diabetes and other things, and so we decided to break down our slide into those categories as well just because it's, you know, it's really illustrating that this partnership goes beyond just getting people connected to the DPP. It's a broader approach to working to address population health without being isolated just in the clinical space, and so the YMCA of Greater Seattle and many YMCAs around the country, you may live in a place where a YMCA is doing these types of chronic disease prevention and management programs in conjunction with their healthcare partners. Yeah, so the last thing I'll say is, you know, the screening and referral pathway is something we've really refined from clinical care and from Valley Medical Center specifically to the YMCA. We have our own EHR, we're getting these patients information, we're texting and calling and reaching them to get them enrolled. But then there's still so many other things to learn and barriers to overcome to get people into the program, to stay in the program, to have success in the program. And this is something that we can talk about in our breakout group, this project overlapped with COVID. So we went from having a pretty large, diverse team of coaches that I oversee in my department to having only a few coaches on staff and a lot of people, because coaching DPP is often a part time job, during the pandemic, they were leaving for various reasons. And a lot of what we've learned through this project is are things that we'll continue to implement as we rebuild from COVID. It's not an easy program for a participant to do and commit to and complete. It's a year of behavior change, it's inherently difficult. It's also not an easy program to deliver. And you really, the program's more successful, the more experience your coaches have. And so if you're training new coaches, or you're, you know, you want to give a coach like five years to get really good at the DPP, because it's a hard program. So anyway, I mean, we've learned a lot, and we will continue to implement what we've learned. That we, from the staffing side, and the program delivery side, and the way that we're inherently as the YMCA, integrated into our community, and we're connecting people to different resources in their neighborhood in their community. These are all things that have helped us to deliver the program and will continue to be And I should add that probably some of you or many of you have heard of the quintuple aim now, which includes health equity, which is very much what this program is about. Okay, now we have a terrific showing. We have a crowded room, and we need to somehow organize it to three groups. I'm going to suggest that on the right-hand side, we have Northeast Valley Health Corporation. So those of you who are interested in a breakout on how to refer within and have an internal DPP program go there. I should say we'll have 20 minutes for a first breakout, and then we'll have another 20 minutes for a second breakout. So you'll have opportunities to have intimate discussions with two out of the three models. So keep that in mind. So we'll have Northeast Valley internal program here. And on the left-hand side, since we've got our Parkland folks over there, if you're interested in referrals between health care systems and learning more about that program, that'll be in the front on the left-hand side. And then in the back, we'll go ahead and have UW. And that's a program where if you're learning to, would like to learn more about how to engage with the community organizations like a YMCA and how that works. So in the back on that side, please go ahead over there. We won't move chairs around, we'll just move bodies around. And we'll keep an eye on the time, 20 minutes, then we'll rotate for another 20 minutes, and then we'll come back for a nice overview wrap-up, keeping in mind key lessons that you all will hopefully walk away with. So thank you. OK, it's time to move to another group. We're wrapping up this first round of discussions. OK, we need to be wrapping up. It's wonderful to have such engaged discussions, but we're pretty much out of time for the session, and we'd like to wrap up. So just a couple of minutes before we end the session. I'm hoping with all of this engagement and discussion that you can answer for yourself what would your immediate, what is your next step for equitably preventing diabetes within your practice setting? So answer that question for yourself. We clearly, I'd love to hear what everyone's answers are, but we're definitely running out of time. I was floating between the groups and I heard issues such as language, having bilingual coaches, issues such as engaging families because patients really care so much about their children and their families and how do we incorporate that into this kind of program. Heard about issues of reimbursement and making sure that our coaches are adequately reimbursed and having systems for that as well as intensive training. I heard the lived experience back there that some of the best champions for the programs are the ones who have been through the program. Some of them can become coaches themselves. So I heard some wonderful messages. I heard about concerns of safety with as promoting physical activity in the program and also heard that in some cases that social isolation, especially through COVID has translated into through this program as an opportunity for social connection and that's a part of the glue of some of the participants and then that year together can fly if they're looking forward to connecting with others in the program. Those are just some things that I heard as I was floating around and I would love to hear a couple of key takeaways from you all. Is anyone willing to share a key takeaway? She's learned about the National DPP and that here she is in her own city, she's finding out that there's a program right there. So that's great. Great that you came here to learn that. Other takeaways? Partnerships are key to making this work even within large systems, between systems, with community organizations, etc. Absolutely, that's what is part of the crux of success, at least from an organizational point of view. More health plans to cover the program, yes. All right, well, terrific. Thank you so much for coming to this session and being actively engaged. Again, I hope you're stepping away from this room with something that you can apply for yourself in your practice settings for yourselves, and enjoy the rest of the conference. Thank you for coming.

Innovative Systems Approaches

Health Equity

Diabetes Prevention

CDC grant

High-risk populations

National Diabetes Prevention Program

Social determinants of health

Interventions

Project partners

Screening and testing

Engaging patients

Social needs barriers

Breakout groups