Diabetes Prevention and Kidney Care

Mission Statement

Diabetes Prevention and Kidney Care

I. Mission Statement

The mission of Diabetes Prevention and Kidney Care (DPKC) is to implement community-based preventive programs, and coordinated primary and specialty care self-management education, --behavioral modification of high risk individuals, integrating evidence-based guidelines into health care delivery for the prevention and treatment of diabetes and co-morbidities. Our primary focus is to promote a healthy lifestyle as a cornerstone for chronic disease management, mainly related to diet and exercise and avoidance of unhealthy behaviors, and to develop effective multidisciplinary chronic disease management models for the prevention, diagnosis, risk assessment and treatment of diabetes and its complications applicable to the population at large and to the Hispanic population in particular. We propose to carry out our program within the framework of a community-based participatory approach integrated with existing health providers and community services. We believe that this approach is practical and culturally appropriate to best promote prevention and self-management of chronic diseases like diabetes in this population. The development of a system tailored to the unique needs of minorities, namely the Hispanic community in the US is highly significant to assure success in halting the rampant rise on the incidence and prevalence of obesity, metabolic syndrome and diabetes.

We understand that social and cultural circumstances that are characteristics of minority populations in the US, result in disparity to access and quality of health care, lack of employer-sponsored health insurance, increased susceptibility to diabetes, metabolic syndrome, and cardio-renal disease, together with the unforeseen rapid growth of the Hispanic population poses a critical problem that requires immediate attention focusing on prevention, self-management and evidence-based multifactorial effective health interventions.

Moreover, it is well recognized that the current health care system in the US is unable to provide cost-effective health care services, resulting many times in wasteful use of limited resources. Also, our health care does not have an integrated system and the ability to improve health care for everyone. "The United States Health Care system does not ensure the efficient and effective prevention of and management of neither chronic diseases, nor does it apply principles of evidence-based medicine" (2). This is happening despite the fact that we have made significant efforts and investment on identifying strategies to improve quality of care, decrease disparities, increase health education, develop guidelines for chronic disease management, establish community health services and many other programs but it appears that it is not enough and, we need to redesign care models to include multidisciplinary efforts in primary care and specialty in order to effectively reduce the burden of renal and cardiovascular end organ disease.

Presently DPKC is providing Nephrology consultation to Community Health Clinics and private primary care practices in Montgomery County, Maryland. However, our efforts are fragmented, uncoordinated and lack funding to provide programs such as self-management support, diet and exercise, behavior modification, coordination of care with primary care facilities which could not have a significant impact on preventing the rapid increase on the incidence of end-stage-renal disease and cardiovascular morbidity in this population. DPKC has implemented a self-management education and preventive programs for diabetes, obesity and for the risk factors for CKD which are carried out in our facility and would like would to extend them to primary care facilities in the community along with the development of a coordinated multifactorial treatment care plans. We have especially trained group Community Health Workers (CHW), who help to carry out our self-management program at home, assists with care coordination and serve as bridges between community members and health care services. Thus CHW is an important component of our comprehensive multidisciplinary team integrated with primary and specialty care, case management, nutritionist, social worker, and diabetes educators. The CHW is a community-based resource to increase access to health care and to carry out preventive programs in the communities they serve.

DPKC ultimate goal is to decrease the progression of diabetic complications, mainly renal and cardiovascular, in the populations at risk. There is evidence that intensive treatment programs could decrease or delay renal and cardiovascular end-points and that the health and economic benefits for these kind of treatment programs would justify the expenses realized by their implementation. In order to provide consultation services and adequate treatment for high risk individuals for cardio-renal disease we have created a clinic, "Diabetes Kidney Care," which operates as our core research and clinical facility. It is located at 121 Congressional Lane in Rockville, MD, where we also provide diabetes education, nutritionist, medication assistance, and nephrology services. Here we train Community Health Workers and coordinate their community services. We also provide a network of consultative services in cardiology, endocrinology, neurology, podiatrist, and ophthalmology.

Our premise is that an intensive multifactorial model for the treatment of diabetes, carried out by a multidisciplinary team, with community participation, including Community Heath Workers specially for ethnic minorities--as liaison and coordinator of care--is the most effective modality for promoting a healthy lifestyle, prevention of obesity and diabetes, and cardio-renal co-morbidities in the population at large, and specially the Hispanic population. However, our multifactorial chronic disease model for the treatment of diabetes to be effective needs to be coordinated and complemented with existing primary care community health clinics, which are first contact for the population at risk. It is at this level where this population should have global risk stratification for developing diabetes, renal, cardiovascular disease and other comorbidities and individuals should have multifactorial management plans and care coordination in order to receive evidence-based quality care. Cost-effective coordinated care at the primary care and specialty settings should result on significant economic savings, on improving quality of life, diminishing disability and human suffering of catastrophic dimensions brought by diabetes epidemic to our nation and especially to vulnerable populations.

II. Objectives of DPKC program

1. Implement self-management education, and behavior modification programs in the community and in primary care setting including community health clinics aimed at reducing the risk of developing obesity, diabetes and their complications.
2. Implement a Community Health Worker Program to coordinate DPKC preventive and chronic disease management programs such as promotion of a healthy lifestyle, health education and diabetes self-management, and take a leadership position in the community as an agent of change in undeserved sectors of the community.
3. Establish partnerships with community organizations and with State programs such as National Plans for Action adopting the framework for improving minority health and decreasing health disparities, and the Maryland Diabetes Prevention and Control Program (DPCP) in order to integrate and coordinate our programs with Community Health Clinics and other services.
4. Promote diabetes prevention programs to individuals at risk, especially the Hispanic population.
5. Provide multidisciplinary medical care to those individuals at risk of diabetic nephropathy and atherosclerotic heart disease in an effort to prevent progression to end stage cardio-renal disease. The program will be targeted especially to the noninsured individuals.
6. Develop a network of culturally competent providers able to serve to the target population.
7. Create the infrastructure for the development of informatics to facilitate sharing of medical records and communication between different health care participants.
8. Identify and apply for Grants and other funding mechanisms.
9. Establish a Diabetes Kidney Care clinic to treat patients identified as having diabetes and are at risk of developing diabetic nephropathy and are at risk of progression.

III Goals of DPKC

1. To reduce the incidence of overweight, obesity, diabetes and co morbidities in the general population and in the Hispanic population, by promoting decreasing overeating and increasing exercise.
2. Strengthen the community self-empowerment with the participation of health providers, community health services, community leaders, social networks, and having at the center the community health workers who will play a central role in the program.
3. 3. Establish and apply prevention and chronic disease treatment model that could effectively reach treatment guidelines goals by the current medical care system.

IV. Diabetes Prevention Programs

1. Diet and Exercise Program. This program is provided to subjects identified to have high risk for developing diabetes and obesity. It includes 6 weeks of "2-hour lectures and home assessment with follow up at 3, 6 and 12 months. This program is carried out in parallel to the "provider training" course that is tailored to "Community Health Worker" who acts as coordinator and coach. For subjects who did not achieve diet and weight goals undergo an intense behavior modification program.

1. Volunteer Program. We provide excellent volunteer opportunities to individuals that believe they can make contribute to our cause on preventing the diabetes and obesity epidemic by becoming active participant on promoting healthy life styles in your own communities starting at home, church, school and work.

• We are especially enthusiastic of our youth volunteer program directed to middle and high school students who bring to their schools and home healthy life style and behavior modification plans to be implemented in daily living.
• Our Community Health Worker Program is directed to coach individuals to make healthier choices, coordinate care and provide assistance for needed services and treatments.
• Community Health Worker. It is a 6 months training program including lectures core curriculum, healthy diet and exercise, motivational interviewing, behavior modification, self-management education, and coordination of care.

1. Clinical Services provided by DPKC. Diabetes Prevention and Kidney Care is organized as a research clinic providing services to subjects with chronic kidney disease who have anemia, uncontrolled hypertension, and other co morbidities who could benefit from a multifactorial treatment modality.
   1. Description of Diabetes Kidney Care facility and services. The facility is located at 121 Congressional Lane, Suite 205 Rockville, MD 20852. Currently, the facility provides outpatient medical care and consultation services, and has administrative office space. We also have laboratory space and phlebotomy services. The services we provide also include nutritionist counseling, diabetes education, and community health worker. Outside our facility we have a network of physicians specialized in cardiology, endocrinology, neurology, podiatry, laboratory, as well as radiology services.
   2. Beneficiaries of DPKC services. These services will be provided to minorities with low income, subjects referred to us by community clinics or providers from the area.
   3. Determination of charges. The charges to individuals will be nominal and less than cost.
   4. Administration and control of DPKC. A health administrator separate from the staff that perform or will perform the clinical services will carry the administration of the organization.
   5. Determination of compensation paid to the professional staff. The compensation will be determined according to IRS Code Section 501 (c)(3). "No part" of the net earnings of a tax-exempt organization can inure "to the benefit of any private shareholder or individual." The business transactions of the DPKC research clinic have not been structured to primarily benefit "insiders." These transactions are made at an arms-length basis (reasonable/fair values). The compensation and reimbursement for expenses are reasonable, and fees for services are customary and reasonable.

V. Research Scope at DPKC

1. 1. Diabetes prevention. The primary focus on diabetes prevention is planning, implementing, and evaluating a program for the prevention of obesity and diabetes by promoting healthy diet and exercise in the population at risk. CDCynergy Social Marketing Edition (developed by the CDC) is the model we use for our program planning. We also apply a Community-Based Participatory framework with the objective to assure the participation of all members of the community and to ensure that behavioral changes achieved will be imbedded into social behavior. Central to the prevention program are Community Health Workers who are active partners and assume leadership roles in the communities where they live.

Goals:

• Asses the needs of the community and barriers for change.
• Develop partnerships with members in all sectors of the community, including schools, churches, government agencies and programs, community health clinics, community leaders, local businesses, who will share DPKC's agenda.
• Carry out a promotional campaign to include the DPKC Healthy Lifestyle flyers, and Brochures.
• Participate in the World Kidney Day and local activities directed at the promotion of healthy life styles.

1. 2. Prevention of renal cardiovascular failure in diabetes. The second focus of our program is related to the amelioration or slowing the progression of diabetic nephropathy and heart disease in those patients who have increased risk of cardiovascular and renal complications including: microalbuminuria, hypertension, hyperlipidemia, and metabolic syndrome. At DPKC we are planning, implementing and evaluating a multifactorial management approach to treat diabetes by a coordinated multidisciplinary management team, which includes a primary care provider, a diabetic and nutritional educator, a diabetologist, a nephrologist and a cardiologist for prompt assessment and coordinated optimal management. Current medical interventions, provided at community clinics and private practices are not achieving the optimal targets guidelines required to prevent progression of diabetic cardio-renal disease. An intensified treatment plan for diabetes to achieve target guidelines should be cost-effective, because of savings gained preventing the staggering expenses related to end-stage cardio-renal disease including hospitalizations, kidney transplantation, and dialysis.

To accomplish our objective we plan to coordinate efforts with primary care settings like community clinics that are taking care of these patients and implement intensive care plans including diabetes self-management with the assistance of specialized care for those subjects at high risk.

DPKC is focused on the investigation of treatment methods for the prevention and treatment of diabetic nephropathy that could be applied to minorities, including the Hispanic population and to the population at large. The model will apply a multifactorial approach together with diabetes self-management in a community-based research program.

Even though the focus of DPKC programs targets minority populations, especially the Hispanic, those programs could be applicable to other minorities and to private health care in general.

Goals:

• Improve quality of care
• Decrease disparities of care
• Provide access to care to underserved minorities
• Coordinate and integrate multidisciplinary services with primary care

1. 3. Our research and grant applications are:
   1. "Reducing the risk of diabetes. A multifactorial Approach."
   2. "Social Marketing to Change Community and Health Care Provider Behaviors on Diet and Exercise aimed to Weight Control. A Community Participatory approach in the Hispanic Community."
   3. "Finding Answers: Disparities Research for Change" To facilitate that community clinics can provide quality diabetes care by providing multidisciplinary care to individuals at risk of developing cardio-renal disease.
   4. Abbott Medical Education Grants. "Preventing progression of diabetic renal disease in the primary care setting."
   5. Lilly Grant: Patient education and awareness of self-monitoring and blood sugar control for the prevention of diabetic complications.
   6. Amgen Grant: Preventive care and patient support: in support for our comprehensive program "DPKC Diabetes Prevention" outlined above, and "Decreasing Health Disparities in our community and increase access to renal care in our Kidney Care Center."

1. 4. Determination and selection of research projects. The research projects are selected by evaluation by The Diabetes Prevention and Kidney Care Scientific Committee.
2. 5. Contemplated sponsored research by DPKC. NIH Program Announcement (PA) Number: (PA-09-124. The Robert Wood Johnson Foundation Clinical Scholars program. Building Human Capital.
3. 6. Disposition of the results of DPKC research. The results of the research will be released promptly for public use and made accessible to community clinics, public health organizations and stakeholders involved in improving health care and diminishing disparities in healthcare delivery.
4. 7. Ownership or control of any patents, copyrights, processes or formulas resulting from our research. DPKC will follow guidelines established on CR 37 401.14, and will be made accessible to the public.

VI. References:

1. HHS in the 21 st Century. Charting a New Course for a Healthier America. Institute of Medicine. http://www.nap.edu/catalog/12513.html
2. Crossing the Quality Chasm: A New Health System for the 21th Century. National Academy Press, Wash DC 2001
3. Gaede, P, et al. Cost-Effectiveness of Intensified Versus Conventional Multifactorial Intervention in Type 2 Diabetes. Diabetes Care 2008; 31: 1510-1515.
4. Marshall, S. Intensive Diabetes Management for High-Risk Patients: How Best to Deliver? Diabetes Care 2009; 32:1132-1133.
5. Chan J, et.al. Effects of Structured Versus Usual Care on Renal Endpoint in Type 2 Diabetes: The SURE Study. A randomized multicenter translational study. Diabetes Care. 2009; 32:977-982
6. Krumholts, HM, et al. A Taxonomy of Disease Management. A Scientific Statement From the American Heart Association Disease Management Taxonomy Writing Group. Circulation 2006; 114:1432-1445.
7. Hill-Briggs, F and Gemmell, L. Problem Solving in Diabetes Self-management and Control. The Diabetes Educator. 2007; 33:1032-1050.
8. Community Health Workers/Promotores de Salud: Critical Connections in Communities. CDC's Division of Diabetes Translation.
9. Community Health Worker National Workforce Study. 2007. HRSA
10. American Diabetes Association. Standards of Medical Care in Diabetes-- 2008. Diabetes Care 2008; 31, Supp 1:S12-S58.
11. American Diabetes Association. Standards of Medical Care in Diabetes-- 2009. Diabetes Care 2009; 32, Supp 1:S13-S61.
12. Gold MR, et al. Cost-Effectiveness in Health and Medicine. Oxford Univ. Press. NY 1996
13. Comparative Effectiveness and Health Care Spending -- Implications for Reform.
14. Folland S, Goodman AC, and Stano M. The Economics of Health & Health Care. McMillian Publishing. NY 1993
15. McKenzie JF, et al. Planning, Implementing & Evaluating Health Promotion Programs. Pearson, 2009.
16. CDCynergy http://www.orau.gov/cdcynergy/demo/

Mario O. Belledonne, MD 2011