Diabesity Community Engagement Project – UniHealth Population Health

Glendale Adventist Medical Center- January 2015 – December 2017

Prevention screening is effective and consistently recommended in many hospital guidelines to improve the community overall health status. UniHealth grant has funded Diabesity (diabetes and obesity) Community Engagement Project to screen 3,000 at risk community participants by December 2017. The multipronged screening program meets five health- related needs in addressing three priorities (reducing overweight, obesity, diabetes prevalence) identified in the Glendale Service Area Community Health Needs Assessment. 35 % of the Glendale Adventist Medical Center (GAMC) Service Planning Area 2 and 4 over 18 are overweight. Higher than LA County, this prevalence can result to increased risk for coronary heart disease, stroke, high blood pressure, type 2 diabetes and other chronic disease. Over 8.6 % of GAMC service area are diabetic, and increasing, of which over half are untreated. Diabetes is a serious co- morbidity disease leading to heart and kidney disease, stroke amputation, blindness and even death. GAMC’s support to access current levels of chronic disease, screen the community and improve chronic disease management health outcomes, let alone improve the community/ patients quality of life, correlates to a decrease in Glendale’s  hospitalization rate for uncontrolled diabetes, currently greater than California. Furthermore, diabetes hospitalization rates are higher among medically underserved areas of Glendale compared to the state.

Each screening takes approximately between 10-15 minutes at collaborating faith-based organizations, for and non-profit organizations, employers, parks and recreational sites. The screenings entail two paper assessments (11 questions for Diabetes and 19 questions for Cardiovascular Risk) and a brief participant information assessment. 2-3 Clinical Care Extender and Nursing residents join to answer immediate questions to aid each participant. Additionally, a Family Practice resident is on site to take blood pressure checks and answer specific clinical questions. Soon comprehensive testing including: HbA1c blood, vision (titmus), spirometry, glaucoma screening, rapid cholesterol and glucose (random), and body fat composition. Plenty of education material and resources are provided at each outreach event including referral to best practice Stanford Diabetes self-management training in a 12 six-week session program offered in Armenian and Spanish.

Barriers such as patient refusal, forgetfulness, culture, language, social economic status or simply lack of time, can all lead to missed opportunities for critical prevention and early detection. To reduce barriers, capture prevalent lower income, and uninsured populations residing in the area, on-site screenings not only facilitates the community to conveniently engage in comprehensive screenings, but also compliments urgent and acute services. The program has partnered with Covered California to provide access to the uninsured community members.

Motivating public to actively “Own their Health” in the community, rather than stigmatize individuals with awareness of disease, DCEP has partnered with local FQHC All for Health, Health for All primary care clinics. In effect, engaged participants will be referred to a primary physician to retain ongoing access self-management tools, extend healthcare needs, increasing compliance, improve patient tracking, and referral tracking, ultimately providing a medical home for patients. Additionally, DCEP has partnered with GAMC Cardiovascular and Heart Institute, offering at risk patients to further CVD counseling and referral to specialists. In conjunction with GAMC new mobile van, DCEP has partnered with Occupational Medicine to engage community employers and businesses. An employee wellness initiative will build on Adventists Health existing program to incentivize healthier workplaces.

Welcoming over 100 partners, Glendale Healthier Community Coalition has collaborated to extend non-profit involvement. Lastly, Health Interoperability Exchange is developing to share a common IT Platform to monitor population health data to continuously assess early disease detection.