AHRQ Annual Meeting 2008 September 10, 2008 Washington, DC Carol Zernial Director

1. Reducing Health Disparities Among Hispanic Elders: Lessons from a Learning NetworkTeam San Antonio AHRQ Annual Meeting 2008 September 10, 2008 Washington, DC Carol Zernial Director Bexar Area Agency on Aging

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.

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%.

4. What is the plan you hope to implement? • Secondary prevention to delay or prevent complications from diabetes. • Pilot in ten 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”

5. 30 plus 20 to 29 10 to 19 1 to 9 none Diabetes Deaths in Bexar Co. 2005 Ages 65 and Olderby Zip codesSource: 2005 Texas Department of State Health Services death certificates # of Deaths by Zip code

6. Who is in the partnership? • Bexar Area Agency on Aging • Metropolitan Health District • CentroMed (FQHC) • Catholic Charities • University Health System Texas Diabetes Institute • UT Health Science Center Barshop Institute on Longevity & Aging

7. 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 Developing Partnerships –roles of each partner

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)

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 and an informed, activated patient – It takes BOTH

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

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 decision-making process

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

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 of electronic medical records. • The funds are available. It is a matter of priorities. Make our health intervention a priority.

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