Reducing Health Disparities Among Hispanic Elders: Lessons from a Learning Network

Slide presentation from the AHRQ 2008 conference showcasing Agency research and projects.

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Carol Zernial made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (692 KB; ).

Slide 1

Reducing Health Disparities Among Hispanic Elders: Lessons from a Learning Network

Team San Antonio

AHRQ Annual Meeting 2008
September 10, 2008
Washington, DC

Carol Zernial
Director
Bexar Area Agency on Aging

Slide 2

Why is your community doing this?

  • In October 2007, the National Association of County & City Health Officials (NACCHO) reported San Antonio having the 2nd highest death rate from diabetes after New Orleans.
  • In Bexar County, 14% (202,250) of the 1.5 million individuals are living with diabetes, with an additional 67,416 individuals undiagnosed.
  • The cost of diabetes in Bexar County alone is $481 million/year or $348 per resident per year.

Slide 3

Why is your community doing this?

  • Among Hispanics age 65 and over, 39,926 have diabetes and another 50,407 are undiagnosed.
  • The rate of diabetes in Hispanics age 65 and over is 34.8%.
  • The incidence of diabetes among older Hispanics in target areas may be as high as 59%.

Slide 4

What is the plan you hope to implement?

  • Secondary prevention to delay or prevent complications from diabetes.
  • Pilot in 10 ZIP codes with the highest incidence of diabetes, the highest incidence of complications, and the highest mortality rates.
  • Focus on improving physician adherence to diabetes standards of care and patient adherence through disease self-management.
  • Community wrap-around supports:
    • Stanford Chronic Disease Self-Management Program (CDSMP).
    • "Diabetes Passport to Better Health."

Slide 5

Diabetes Deaths in Bexar County 2005 Ages 65 and Older by ZIP Codes

The map outlines ZIP code areas in the county, with colors indicating the numbers of deaths from diabetes in 2005 according to Texas Department of Health Services death certificates. Although the ZIP code numbers themselves are not shown, deaths from diabetes are clustered in about a dozen ZIP code areas near the center of the county. Death rates in them ranged between one to nine during 2005 up to more than 30. Many surrounding ZIP codes showed no deaths during the same year.

Source: 2005 Texas Department of State Health Services death certificates.

Slide 6

Who is in the partnership?

  • Bexar Area Agency on Aging.
  • Metropolitan Health District.
  • CentroMed (Federally qualified health center [FQHC]).
  • Catholic Charities.
  • University Health System Texas Diabetes Institute.
  • UT Health Science Center Barshop Institute on Longevity & Aging.

Slide 7

Developing Partnerships-roles of each partner

  • Clinical Partners:
    • Survey capacity of providers to adhere to guidelines.
    • Identify barriers and facilitators to adherence.
    • Develop, disseminate, and support utilization of a community diabetes scorecard for providers to track progress in preventing complications.
    • Support consistent messaging for project in community.
  • Community Partners:
    • Offer Stanford Chronic Disease Self-Management in nine ZIP codes in churches, senior centers, parks & rec, and senior housing.
    • Disseminate and educate about a "Diabetes Passport to Better Health" to reinforce adherence guidelines.
    • Support consistent messaging for project in community.

Slide 8

Texas Diabetes Institute Scorecard— American Diabetes Association (ADA)/National Committee for Quality Assurance (NCQA) Diabetes Recognition Report, 2004 Results

Standards of Care CriteriaTDIADA GoalStatus
At least one test documented   
% patient with HbA1c <8%97%93%Green
% patient with HbA1c >9.5%13%≤21%Green
Yearly eye exam69%61%Green
Yearly foot exam89%80%Green
Blood pressure (BP) at least BP documented100%97%Green
% patients with systolic BP mm Hg <140/9073%65%Green
Monitoring for Nephropathy94%73%Green
Lipid control (% patients with low-density lipoprotein [LDL] <130 mg/dll)94%63%Green

Slide 9

Texas Diabetes Institute Scorecard— ADA/NCQA Diabetes Recognition 2007 Results

Standards of Care CriteriaTDIADA GoalStatus
Patients with HbA1c <7%43%≥40%Green
Patients with HbA1c >9%16%≤15%Red
Yearly eye exam63%≥60%Green
Yearly foot exam93%≥80%Green
Patients with BP <130/80 mm Hg53%≥25%Green
Patients with BP >140/90 mm Hg23%≤35%Green
Monitoring for Nephropathy92%≥80%Green
Lipid control (Patients with LDL <100 mg/dL)69%≥36%Green
Lipid control (Patients with LDL ≥130 mg/dL)13%≤37%Green

Slide 10

How did the team build capacity before engaging clinical partners?

  • AAA and community partners have been developing expertise in delivering evidence-based disease-prevention and health promotion activities since 2003:
    • Diabetes Prevention Program (DPP).
    • Stanford Chronic Disease Self-Management Program.
    • Matter of Balance Falls Prevention.
    • Arthritis Foundation Exercise Program (formerly PACE).

Slide 11

How is the team engaging clinical providers?

  • Very few programs are targeting prevention in the older population, particularly among older Hispanics.
  • Consumers spend more time in the community setting. Consistent messaging reinforced between clinical and community settings.
  • Physicians only compare their scores against the entire project.
  • Respect each health system. Come to table as health care providers versus recruiters.
  • Improvements come from a prepared, proactive practice team AND an informed, activated patient—It takes both.

Slide 12

Accomplishments

  • First meeting for community stakeholders in May 2008.
  • $20,000 foundation grant to bring Stanford CDSMP Master Training to Bexar County in October 2008 to increase capacity in targeted zip codes.
  • Finalizing a diabetes scorecard to be adopted.
  • The Hispanic Elders Project has significantly enhanced the communication between the clinical services and the social services around diabetes and generated interest in collaborating for other initiatives.

Slide 13

How was the Learning Network helpful?

  • Lessons learned within this network are transferred to individual team member networks (i.e, AAA associations, public health agencies, etc.).
  • Team-to-team learning within the project was very important-building on each other's knowledge.
  • Having access to clinical expertise from George Washington University Department of Prevention and Community Health was invaluable in the decisionmaking process.

Slide 14

Most Challenging Aspect

  • Identifying barriers to improving adherence to diabetes standards of care.
  • Identifying incentives for clinicians to adopt the diabetes scorecard.
  • Overcoming fear of losing patients to other providers.
  • Communicating to the network of clinicians in target area.

Slide 15

Lessons Learned

  • Composition of the teams with national support has been the largest asset to the project.
  • Need multiple outreach strategies for different physicians (i.e., HMO, physician groups, independent physicians).
  • Incentives to participate are difficult:
    • Financial incentives have not worked in the past.
    • Physician time is linked to reimbursement, and therefore, often limited.
    • Not all offices use electronic medical records.
  • The funds are available. It is a matter of priorities. Make our health intervention a priority.

Slide 16

For More Information

Carol Zernial, Director
Bexar Area Agency on Aging
8700 Tesoro Drive, #700
San Antonio, TX 78217-6228
czernial@aacog.com
210-362-5268

Current as of February 2009
Internet Citation: Reducing Health Disparities Among Hispanic Elders: Lessons from a Learning Network. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2008/Zernial.html