Bridging the Gap—addressing disparities in health systems with Drs. Marshall Chin and Monica Peek

Association of Diabetes Care & Education Specialists – The Huddle: Conversations with the Diabetes Care Team

Description

Those who work with people with diabetes know that there are significant disparities in diabetes outcomes influenced by social drivers of health. To address these issues, health systems need to engage with disadvantaged communities and address community needs. On this episode of The Huddle, Drs. Marshall Chin and Monica Peek, internal medicine physicians at the University of Chicago, discuss a national initiative to address health disparities in diabetes care called Bridging the Gap.

Resources

Collaboratively addressing food insecurity during COVID-19 in urban environments

Description:

In the absence of comprehensive economic and antihunger policies, emergency food systems and healthcare organizations have organized to meet increasing demand during the COVID-19 pandemic. In this webinar, we heard from two collaboratives about their strategies to address acute food insecurity in urban environments. We heard how their strategies were tailored to their specific populations and what lessons they’ve learned that can be applied to other organizations and cross-sector initiatives.

Cross-sector collaborative: Matthew Broad from the Trenton Health Team (THT), a non-profit public health collaborative, and Pamela Sims Jones from Mercer Street Friends, a local food bank, shared how they collaborated with a network of 50+ organizations to respond to specific food access needs during the pandemic in Trenton, NJ.

Health system-based collaborative: Heidi Davis from Providence Health & Services and Emily Motter from Ride Connection, a non-profit providing transportation support services, discussed their partnership and how integrated food and healthcare services in a hospital-based environment revealed opportunities to eliminate stigma and barriers associated with seeking food and education in Portland, OR.

This webinar was one of a three-part webinar series featuring grantees of the Bridging the Gap: Reducing Disparities in Diabetes Care, a five-year initiative supported by the Merck Foundation that aims to improve access to high-quality diabetes care and reduce health disparities for vulnerable populations with diabetes. Although the initiative focuses on people living with diabetes, their experiences with integrated medical and social care and cross-sector collaboration can be extended to support individuals living with a range of complex chronic health conditions and social needs.

Presenters:

• Matthew Broad, MPH, Program Manager, Trenton Health Team
• Pamela Sims Jones, Program Associate, Mercer Street Friends
• Heidi Davis, MSW, Community Teaching Kitchen Manager, Providence Health & Services
• Emily Motter, Deputy Director, Ride Connection
• Katie Gunter, MPH, MSW, Deputy Director, Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, University of Chicago

Building partnerships to care for immigrant communities during COVID-19

Description:

COVID-19 has compounded long-standing economic and health disparities, disproportionately affecting Latinos and other people of color. The CARES Act did not confer equal access to stimulus relief or Medicaid to immigrants who are more vulnerable due to roles in essential jobs. To address these structural inequities, organizations like La Clínica del Pueblo in Washington, D.C. are rapidly transforming services to improve healthcare and social care access.

In this webinar, Rodrigo Stein and Manuel Diaz-Ramirez from La Clínica del Pueblo described how La Clínica integrates healthcare and social care within a safety-net for immigrant patients, anchored in human connection and shared culture and language. Rodrigo and Manuel were joined by Dalila Boclin from FRESHFARM to share the cross-sector solutions that connect clients to accessible food distribution tailored to their needs and preferences.

This webinar was one of a three-part webinar series featuring grantees of Bridging the Gap: Reducing Disparities in Diabetes Care, a five-year initiative supported by the Merck Foundation that aims to improve access to high-quality diabetes care and reduce health disparities for vulnerable populations with diabetes. Although the initiative focused on people living with diabetes, their experiences with integrated medical and social care and cross-sector collaboration can be extended to support individuals living with complex chronic health conditions and social needs.

Presenters:

• Rodrigo Stein, Director of Health Equity and Strategic Partnerships, La Clínica del Pueblo
• Manuel Diaz-Ramirez, Director of Community Health Action, La Clínica del Pueblo
• Dalila Boclin, Director of Programs, FRESHFARM
• Katie Gunter, MPH, MSW, Deputy Director, Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, University of Chicago

Building trust through community health workers in a rural environment

Description:

Supporting health-related social needs is increasingly recognized as important in addressing health disparities among vulnerable patients, but a patient’s willingness to engage in social needs screening and support requires trust in their care team. Rural communities’ emphasis on self-reliance and general distrust of institutions are barriers providers often face when seeking to develop trust with rural patients. At St. Mary’s & Clearwater Valley Hospital and Clinics, a rural healthcare organization serving the North Central Idaho community, community health workers (CHWs) are uniquely positioned in care teams to develop strong relationships with patients through community health events, home-based screening, and coordinating clinical and social care.

During this webinar, we welcomed Vicky Peterson, Barbara Cleary, Leah Kaschmitter, and Christine Packer from St. Mary’s & Clearwater Valley Hospital and Clinics to share the barriers they face in gaining the trust of their community and the effective elements of a CHW-based program that lead to trusted interpersonal relationships and greater patient engagement.

This webinar was one of a three-part webinar series featuring grantees of the Bridging the Gap: Reducing Disparities in Diabetes Care, a five-year initiative supported by the Merck Foundation that aims to improve access to high-quality diabetes care and reduce health disparities for vulnerable populations with diabetes. Although the initiative focuses on people living with diabetes, their experiences with integrated medical and social care and cross-sector collaboration can be extended to support individuals living with complex chronic health conditions and social needs.

Presenters:

• Barbara Cleary, CHW, St. Mary’s & Clearwater Valley Hospital and Clinics
• Christine Packer, Performance Improvement Officer, St. Mary’s & Clearwater Valley Hospital and Clinics
• Leah Kaschmitter, CHW, St. Mary’s & Clearwater Valley Hospital and Clinics
• Vicky Peterson, Clinic Director, Clearwater Valley Hospital and Clinics
• Rich Gauthier, MBA, MA, Program Manager, Bridging the Gap: Reducing Disparities in Diabetes Care, University of Chicago

Minnesota Association of Community Health Centers (MNACHC) Diabetes Roundtable Learning Series

The Minneapolis Health Department and the Minnesota Association of Community Health Centers (MNACHC) share the learnings and results from three health centers that participated in the Merck Foundation’s Bridging the Gap: Reducing Disparities in Diabetes Care initiative. This has been a five-year effort focused on improving diabetes outcomes through transforming clinical care, enhancing diabetes education, and building community partnerships to address patients’ social needs. To disseminate valuable learnings, MNACHC hosted a 3-part roundtable series dedicated to the following diabetes quality improvement topics.

Session #1: Diabetes Care and Education Models
Tuesday, April 26th

Session #2: Assessing Social Determinants of Health
Tuesday, May 24th

Session #3: Integrating CHWs to Address Social Determinants of Health
Tuesday, June 28th

Presenters include staff from Native American Community Clinic (NACC), Neighborhood HealthSource (NHS), Southside Community Health Services, and CHW Solutions.

Multidisciplinary Team Improves HbA1c Outcomes Among Patients with Diabetes in Rural Idaho.

Kuther S, Wilkinson C, Kaschmitter L.
Virtual Presentation at Institute for Healthcare Improvement Forum 2022, December 2022.

Cross-Sector Collaborations to Address Population Health Needs.

Wilkinson C, Cleary B.
Panel presentation at Population Health Colloquium, November 2022.

Hospital-based, community teaching kitchen integrates diabetes education, culinary medicine, and food assistance: Case Study during the COVID-19.

Christensen J, Davis H, Tanumihardjo JP.
Poster presentation at Teaching Kitchen Research Conference, October 2022.

Leveraging Payment Reforms to Improve Care for Rural Patients with Diabetes: Lessons from UPMC Western Maryland.

Wang G, Gunter KE, Johnson L, Zhu M, Wan W, Tanumihardjo JP, Chin MH.
Poster presentation at AcademyHealth Annual Research Meeting, June 2022.

New Frontiers in Diabetes Care: Multidisciplinary Population Health Team Improves Diabetes-Related Outcomes for Patients in Rural Critical Access Hospitals.

Tanumihardjo JP, Gunter KE, Wan W, Zhu M, Kuther S, Wilkinson C, McGrath K, Packer C.
Poster presentation at AcademyHealth Annual Research Meeting, June 2022.

Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes.

Gunter KE, Peek ME, Tanumihardjo JP, Carbrey E, Crespo RD, Johnson TW, Rueda‐Yamashita BR, Schwartz EI, Sol C, Wilkinson CM, Wilson JM.
Poster presentation at AcademyHealth Virtual Annual Research Meeting, July 2020.

Using a Health Information Exchange to Implement a Diabetes Risk Stratification Model to Address Medical and Social Needs across Trenton, New Jersey.

Kraus R, Terens N.
Poster presentation at AcademyHealth Virtual Annual Research Meeting, July 2020.

Embedding Community Health Workers in Frontier Idaho’s Food Banks and Pantries to Reach Populations with Unmet Need.

Sommers IJ, Gunter KE, McGrath KJ, Wilkinson CM, Kuther SM, Peek ME, Chin MH.
Poster presentation at AcademyHealth Virtual Annual Research Meeting, July 2020.

Beyond Referrals: Innovating Practice Transformation Strategies to Address Social Needs for Latino Immigrants Managing Diabetes.

Suarez A, Barker S, Stein R, DeOliveira L.
Abstract, NCEAS Annual Conference, June 2020, Chicago, IL.

New Jersey Health Collaborative Better Understands Social Determinants of Health Barriers at Community Health Screenings.

Grant Z.
Abstract, NCEAS Annual Conference, June 2020, Chicago, IL.

Bridging the Gap in Diabetes Care: Cross Sector Partnerships to Address Social Determinants of Health among Person with Diabetes.

Peek, ME, Chin MH, Wilkinson C, Barker S, Smith R.
Virtual Presentation, Symposium at the Annual Meeting of the Society of General Internal Medicine, April 2020.

Best practices for Addressing Internal and External Challenges of Social Needs Screening and Closed-Loop Referrals.

Carlson K, Forlifer N, Gunter KE, Morganstern E, Terens N.
Poster presentation at Putting Care at the Center, November 2019, Memphis TN.

Lessons for Payment Models to Reduce Health Disparities.

Gunter KE.
Poster presentation at AcademyHealth’s Annual Research Meeting, June 2019, Washington, DC. https://academyhealth.org/sites/default/files/arm_2019_agenda_final.pdf

Cross-Sector Collaboration to Improve Population Health and Reduce Diabetes Disparities.

Gunter KE.
Poster presentation at AcademyHealth’s Annual Research Meeting, June 2019, Washington, DC. https://academyhealth.org/sites/default/files/arm_2019_agenda_final.pdf