Problem Addressed: Diabetes/Hypertension

Healthy People 2010 Objective: 5, 12

Web Address: None

SNAPSHOT

Delta Community Partners in Care (DCPIC) is a coalition of 19 partners serving a 10-county rural area in the Mississippi Delta region of northwest Mississippi. This region’s economy is based primarily on agribusinesses associated with raising soybeans, cotton, and catfish. This is a historically underserved area for health care, where 29.5 percent of the population lives below poverty. Its target population is the uninsured or underinsured between the ages of 21 and 64 who have a diagnosis of diabetes, hypertension, or both. The demographics are 92.1 percent African American, 7.6 percent white, and 0.3 percent other.

DCPIC attempts to reduce the barriers affecting its target population by providing outreach case management services. These services include case management, financial assistance, transportation to provider clinics for assistance, referral and follow-up of social issues presenting barriers to a patient’s response to care, individualized health education/self-care planning, and organized support services, such as support groups, walking groups, etc. Community health education programs are also provided for the community residents throughout the target area.

THE MODEL

Blueprint: DCPIC is a 501(c)(3) non-profit organization with a Board of Directors and elected officers. The original stakeholders are still involved in the program. The operation has grown to include 19 collaborative partners: four hospitals, four Federally Qualified Community Health Centers (FQHC), three rural health centers, two state department of health districts, one mental health center, three state agencies, and two federally funded agencies. Currently, funding is from the Health Resources and Services Administration (HRSA), and DCPIC has an advisory council composed of representatives from the partnership members. The lead agency for the HRSA grant is one of the original members and an FQHC. Staff includes five persons at the central office and a caseworker at each of the 19 clinical sites.

DCPIC uses a community-based case management model to improve the health status and risk factors in its target population. Caseworkers are trained social workers, nurses, and lay health workers who work directly with patients who have a diagnosis of diabetes, hypertension, or both. The caseworkers use a holistic approach, and the environment is such that the caseworkers and patients are able to learn from each other. As required by HRSA funding, they use several prevention indicators: reminders for doctors to perform foot checks, Hemoglobin A_1c(HbA_1c) tests every six months, and annual eye exams.

Making a Difference: From its modest beginnings, DCPIC has grown to provide comprehensive community-based education, prevention, and treatment services for 1,570 patients. In this growth, they developed extensive tools and materials for their program. A baseline survey provides a patient profile at enrollment; all tracking and data collection forms are standardized, and training materials have been developed for staff. Health status surveys, knowledge assessments, health profiles, and patient satisfaction surveys are used to gather information on the program’s success. Indicators employed not only measure the effectiveness of the program but are also used to identify key policy issues for change. These indicators are decreases in multiple clinic utilization, emergency services utilization for primary care, the number of nights hospitalized, and the amount of sick and bed days; an increased knowledge of high blood pressure and diabetes, an increased utilization of primary care, health status changes, better blood pressure and sugar control, patient satisfaction, and improved overall health. The University of Mississippi Research Institute of Pharmaceutical Sciences provides ongoing statistical analysis and outcomes assessments.

In their Final Outcome Evaluation in 1999, prepared by the University of Mississippi Preventive Medicine Department, many successful outcomes were reported. Of the clients currently enrolled at the time the data were collected, emergency room utilization in the past year had decreased significantly from 1.01 visits to 0.65 from time of entry into the program to the time of the study. The number of outpatient visits in the last year decreased from 0.68 to 0.31; and of the patients hospitalized in the past year, the number of nights stayed decreased as well from 6.37 nights to 3.40. The number of sick days in the past year also declined, dropping from 26.74 days to 15.77. Not only did the physical health of the enrollees seem to improve but their knowledge of their conditions did as well. Knowledge of both hypertension and diabetes increased significantly, corresponding with an increase of the patients’ ability to control their own blood pressure and blood sugar. A new study is currently being planned comparing patients who have been in the program since its inception to newer patients, for the 21 to 64-year-old age group.

Beginnings: DCPIC began as a vision of the Northwest Mississippi Regional Medical Center (NWMRMC) in Clarksville, from concerns in the local medical community. Greater than expected numbers of patients were presenting in the emergency rooms or were found to have previously undiagnosed diabetes, were suffering strokes, or were requiring amputations. Young patients were also developing hypertension and strokes. The uninsured and underinsured chronically ill population faced many barriers in accessing health care services that resulted in poor health outcomes. Community meetings were held to identify these barriers as well as other existing problems within the health care systems.

It was originally a grassroots operation involving four hospitals, one community health center, three state agencies and three rural health centers, to serve a five-county area. DCPIC received a planning grant from the W.K. Kellogg Foundation for the period from May 1, 1994, through April 30, 1995. The planning committee consisted of representatives from NWMRMC, health care providers within a 15 to 30-mile radius of NWMRMC, and the Mississippi Division of Medicaid. During the planning stage, meetings were held with providers in each county. The planning was implemented in 1996, and funding ended in 1999. DCPIC had a HRSA Community Access Program (CAP) grant for evaluating sustainability.

Challenges and Solutions: Initial funding ended in 1999, creating a challenge to program continuation. DCPIC is brought to the attention of potential funders through presentations at state and national conferences as well as in published articles. Funding is continuously being sought; however, the program has maintained its focus.

PROGRAM CONTACT INFORMATION

Lela Keys

Delta Community Partners in Care

P.O. Box 1218

Clarksdale, MS 38614

Phone: (662) 624-3484

Fax: (662) 624-3203

E-mail: lbkeys2@bellsouth.net