Southwest Diabetes & Obesity Consortium

Project Title: Early Identification, Recruitment and Intervention of Diabetes and Obesity Project

Proposal ID: Unsolicited

Applicant Name: Arizona Diabetes Foundation dba Southwest Diabetes and Obesity Consortium

Legal Name of Applicant Organization: Arizona Diabetes Foundation

  1. Description of the project.

The seven barriers to healthcare for minorities:  uninsured, underinsured, underserved, underrepresented, uninspired, untrusting, and uniformed.  Our proposal will provide an innovative approach to addressing the last five barriers.

This model will improve the health of populations defined geographically (health of a community), clinically (health of those with diabetes and obesity), and by socioeconomic class through activities focused on recruitment, engaging participants, diabetes prevention, wellness and comprehensive care that extend beyond the clinical service delivery setting.  Recruitment of minorities that may not be aware that they are or potentially are diabetics is the keystone of our project. The model will reduce the cost of Medicare and Medicaid beneficiaries and provide care for those without any resources by:

  1. Early recruitment, interventions and detection in order to prevent progression of the disease state to avoid major cardiovascular events and end stage renal disease.
  2. Reduction of emergency room and prolonged hospital visits.
  3. Facilitating the enrollment into ACA through use of in-house navigators.
  4. Electronically monitoring the care of patients in order to make care corrections when necessary and to create a data base for evaluation of the model.
  5. Provide culturally sensitive education and information to patient, family and community to reduce overall cost per patient by improving their decision-making ability to deal with the disease.

This approach will change the business of dealing with minorities with type 2 diabetes by introducing a group of community health workers referred to as “promotores”.  These trained community health care workers will work directly with the participants to insure that the patients understand the disease and their medication, the importance of visiting their healthcare provider on a regular basis that will lead to a reduction in the mild to severe effects.  They will also to increase the trust between the patient and the healthcare provider.

Additionally, the use of a mobile units-MOR, allows for these key organizations and its partners to reach pre- diabetic, diabetic and obese populations which have been rapidly rising including individuals with other existing medical conditions and disabilities that may not have been served or treated in the past. The program is designed to serve as a preventive medical measure that once in place should be extremely beneficial in providing the medical care needed by these populations. These measures are also envisioned to serve as a medical cost containment initiative due to early illness detection for the States of Arizona and New Mexico as well as national health programs. The current national data indicate that any Hispanic child born from the year 2000 and on has a 50% probability of developing type 2 diabetes. Early detection and intervention is crucial in managing this disease along with close monitoring on a long term basis. The present AACE recommendations are to screen and detect any fasting glucose of greater than 100 mg % as an at- risk patient that will require further evaluation and management. Family history and over-weight are also critical considerations. The current statistics on a national level has indicated that the average A1C in the US is 9 with only 17 % of diabetics treated to target goals for A1C, lipids and blood pressure leading to 50% of hospitalizations related to a discharge diagnosis including diabetes.

The target population includes Medicare and Medicaid patients of Hispanics race and ethnicity located in Arizona and New Mexico.  The age of the beneficiaries will range from 18 to 75 plus years. This does not preclude providing services to other populations. It is anticipated that we will be serving more than 6,000 Medicare and Medicaid individuals over the three (3) year period. There will be four major service providers, including the Southwest Diabetes & Obesity Consortium Clinic, the Mission of Mercy, Arizona; and they are:

  • Arizona Diabetes Foundation dba
  • Southwest Diabetes & Obesity Consortium –Awardee
  • Mission of Mercy, Arizona
  • New Mexico Hispanic Medical Association
  • Sereno Group

The elements included in this model are important to the overall expected impact of the model because the target population has historically been difficult to serve due to cultural and ethnic standards of the community. This population has been continuously underserved due to lack of medical care accessibility, lack of culturally sensitive medical professionals that serve the target population, and lack of culturally and ethnic education, advising and counseling available. Since the target group is at moderate to high risk for severe diabetic disease complications, the model, if proven effective, would be highly suitable to other populations, settings and geographical areas that have the same or less level of diabetic beneficiaries. The following measures will be utilized to monitor the model’s effectiveness:

Percentage of members 18-75 years of age with type 2 diabetes who received a nephropathy screening test or had evidence of nephropathy during the measurement year.

Percentage of adult patients with diabetes or at risk for diabetes 18 to 75 plus years who received a hemoglobin A1c and lipid profile assessment during the measurement year

Percentage of adult patients with diabetes or at risk for diabetes 18 to 75 plus years who have achieved target blood pressure, lipid, and A1C goals.

Percentage of reduction of visits by beneficiaries to local emergency rooms and hospitals.

The beneficiaries’ data will be collected electronically and compiled as reports to be periodically reviewed for evaluating the model.

The model is a strong strategic match for the missions of the lead applicant and its partners.

The Southwest Diabetes and Obesity Consortium was established specifically to address the diabetic epidemic of Arizona and New Mexico. Its mission is to collaborate and/or form partnerships with other healthcare institutions within the geographic region to address the identification, assessment, treatment and education of pre and diabetic patients in order to prevent them from moving on to the more critical stages of the disease

The Southwestern Diabetes and Obesity Consortium’s mission is “Improving the Care of Diabetes through Education and Treatment”. The Arizona Diabetes Foundation dba Southwestern Diabetes and Obesity Consortium for this grant was founded and granted a 501c 3 IRS designation in 2007. Its major goal is to enhance diabetes awareness and to promote healthy lifestyles. It has provided type 2 diabetes educational seminars to the general public since its inception with over 5000 participants having attended these seminars.

The Sereno Group was created to further the education of Hispanics so that they become productive citizens. The Alliance, a non-profit organization, was established as the Sereno Group, a for-profit organization, in 2000 and has held several national conferences on Hispanic higher education policy. The Alliance has worked with several post-secondary institutions to further the education of Hispanic professional. Most recently, the Alliance was successful in garnering a Department of Labor grant ($5 million) for Banner Healthcare to train more Bachelor of Science Nurses.

Mission of Mercy—History

Since 1997, Mission of Mercy (MOM), a 501c3 non-profit organization, has restored dignity to the sick, working poor, underinsured and uninsured by providing free healthcare, prescription medications and a compassionate medical home for those who have nowhere else to turn. In the simplest of terms, MOM provides a high-quality, no-cost medical care for Maricopa County’s most medically underserved families and individuals for as long as they need it – without a penny of public funding or a dime of taxpayer’s dollars.

Utilizing the skills of over 300 medical and support volunteers, MOM operates six bi-lingual free mobile clinics out of churches, schools and community centers in Maricopa County neighborhoods of severe unmet need to include Avondale, Central Phoenix, Maryvale, Mesa, South Phoenix and South Central Phoenix. MOM’s two fully-equipped mobile medical units travel daily to different clinic locations where they set up full-scale primary care clinics to include a full pharmacy. After an in-depth environmental health scan conducted by an outside health consulting firm, and at the invitation of several East Valley communities, MOM has successfully raised private funds to purchase a third mobile medical unit and is currently raising necessary operating revenue to expand our footprint into three new clinic sites in the East Valley (the Town of Gilbert, East Chandler, and Apache Junction) over the next three years.

In 2015, over 20,000 free prescription medications and more than 15,000 no-cost patient visits were provided at MOM clinics. Approximately 60% of MOM patients utilize MOM as their medical home where two-out-of-three patients suffer from at least one chronic illness, predominately diabetes.  Currently, we accept and treat approximately 100 new patients per month. Patients are provided with a continuum of medical care focused on treating the “whole person” through individual primary care visits, patient education and prescription medications – all free of cost. Specifically, each MOM patient receives:

  • Diagnosis, treatment and follow-up care for acute and chronic conditions such as hypertension, asthma, cardiac/lung disease (COPD), obesity and, most predominately, diabetes;
  • Prescription medications and 1:1 personalized patient education as indicated by diagnosis;
  • Screenings, tests, diagnostic labs and follow-on supportive services such as mammograms and on-site diabetic education and nutrition/physical activity classes;
  • Referrals to appropriate specialty care practitioners for advanced care not available at MOM clinics;
  • Free diagnostic imaging and laboratory testing through our Compassionate Care Partnerships with Sonora Quest Laboratories and local Valley anchor hospitals (St. Joseph’s Hospital and Medical Center (SJHMC), Dignity Chandler Regional Hospital and Medical Center, Dignity Mercy Gilbert Hospital, Dignity Westgate Hospital and Banner Estrella Mountain and University         Medical Centers);
  • Community Connections Health Literacy and Education Program – provides onsite chronic disease management and healthy lifestyle choices education (i.e., Living with Diabetes and Stanford University’s Chronic Disease Self-Management Program (CDSMP) classes); and
  • Onsite benefits eligibility navigation to assist patients to confidentially pre-qualify for services such as the Arizona Health Care Cost Containment System (AHCCCS), Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Women, Infants  and Children (WIC) and referrals to other social and behavioral health services.

 Who We Serve

MOM’s patient population is made up of Arizona’s 1-in-4 uninsured and 1-in-5 underinsured children and adults of all ages. These are the working poor and the medically homeless that have fallen through the cracks of state and federally funded healthcare programs. They are the elderly, refugees, undocumented workers, homeless and underserved veterans – those who cannot afford rising premiums and co-pays of healthcare plans, or cannot access health insurance on the national healthcare exchange due to immigration or under-employment status.

Eighty-five percent of MOM patients identify as racial and ethnic minorities, mostly Hispanic, and have low income, limited English proficiency, low educational attainment and low health literacy. Our patients also face other “social determinants of health” that make access to quality health an ongoing and multi-generational challenge. These factors include insufficient access to healthy food, reliable transportation, safe housing, steady employment, etc.  For almost 20 years MOM clinics have been the last resort for those who have nowhere else to turn.

Chronic Disease Management

More than 70% of MOM’s patients suffer from chronic illnesses such as heart disease, obesity, and diabetes, all of which require close monitoring and ongoing management. Without a established medical home, vulnerable families and individuals suffer undiagnosed and untreated chronic illness; unnecessary and costly hospital emergency room care for illnesses that have gone untreated and have become acute; lost employment; stress on fragile family units; and, in many cases, preventable premature death.  In addition to providing primary medical care and prescriptions, MOM is actively addressing other factors impacting working poor families through our Community Connections Program which offers chronic disease management, personalized patient education and supplemental community resources and support services.

Quality and Efficient Health Care Delivery

MOM’s mobile healthcare delivery model is highly efficient and is 100% privately funded and uses no public or tax dollars. MOM’s small clinical staff includes just one full time medical director and five part time medical support staff (two physicians and three clinical nursing supervisors) augmented by more than 300 passionate and dedicated volunteers (doctors, nurses, medical assistants, interns, Interpreters, and engaged non-medical community members), who deliver high-quality health care at a cost of just over $68 per patient visit, which includes all the patient visit components listed above. Care is delivered by a team of highly-proficient medical professionals who bring skill, compassion and a commitment to serve, to every patient they encounter. Patient visits are never rushed, and patients receive all the time they need to discuss their challenges – medical, environmental and social. Scheduled appointments help reduce costly time away from work and are the norm for most of MOM’s patients, although a limited number of walk-ins can be accommodated daily. Our commitment is to restore dignity, empower patients and strengthen communities by removing barriers to care.

Over the past 19 years, MOM has built an extensive referral network of community partners who provide free follow-up support for almost any type of medical issue, surgical, pre-natal, pediatric, cancer, dental, etc.

In addition, innovative pro bono community partnerships enrich patient services and keep MOM’s per patient visit costs low.  Some of our established health partners include:

  1.  Sonora Quest Laboratories (SQL) has been a health care champion and community partner to Mission of Mercy (MOM) Mobile Health Clinics since our first clinic opened in Central Phoenix in 1997.  Through this partnership, SQL has provided free laboratory and diagnostic services for tens of thousands of Maricopa County’s most medically underserved and uninsured families. SQL’s generous donation of full laboratory services has been an incalculable gift that has allowed MOM to more accurately address the growing medical needs of our patients. Not only has SQL partnered with MOM for almost twenty years, they have grown with us over the years and will continue to provide “no cap” pro bono lab services for all MOM’s current and future clinics, including all MOM’s proposed  expansion sites.
  2. Dignity Health’s four hospitals and medical centers continue to serve as “anchor” hospitals for MOM patients who need immediate hospitalization for serious health care conditions beyond our scope to treat.  Dignity Health and MOM share similar mission statements and core values, making them ideal community health partners. Dignity compassionately shepherds our indigent patients through their Charity Care/emergency AHCCCS (Medicare) process and assists in qualifying many for surgeries, chemotherapy and other life-saving interventions. MOM is year two of a pilot “Medical Home/ER Diversion Program” to provide a free post-discharge primary care medical home for uninsured patients in exchange for access to specialty care hospital services – strengthening the continuity of care circle and minimizing costly and unnecessary hospital readmissions due to a lack of an ongoing medical home.
  3. Churches and Community Sites throughout Maricopa County generously donate working space for MOM to set up virtual primary care clinics to include pharmacy services.  We are grateful to our community for meeting us at our patients’ point of need.  Many of our church hosts become highly involved with our medical program by providing numerous clinic volunteers and providing financial support. But most important, churches and neighborhood community centers provide a sense of safety and confidentiality to our patients in a way that government health centers and public health facilities cannot.

Uniting for Impact—A New Way of Health Care Delivery

We greatly appreciate the interest of the Robert Wood Johnson Foundation in finding a way to “build a bridge” between traditional health insurance programs and community clinics like Mission of Mercy.

  • Chronic Disease Partnership – reduce unnecessary emergency room visits through our “Living with Diabetes” and other chronic disease patient education programs.
  • Primary Care Referral Program – for patients who are underutilizing their health policies, insurance companies and hospitals can refer clients and policyholders to any of our free clinics for short or long-term medical assistance.
  • No Place Like Home Medical Home Navigation Program – By providing on-site navigators, MOM confidentially qualifies our patients for AHCCSS, KidsCare and other health and social support resources to address their specialty care needs.

MOM’s Greatest Needs

For MOM to remain vital and sustainable, we rely on volunteers, community partnerships and private/foundation funding.  Our patients face far more than a lack of health care. They wrestle with grinding poverty, obesity, homelessness, violence, poor nutrition and all of the multi-generational social determinants of health that keep them from living healthy and productive lives.

Through a best-practice chronic illness screening and early diabetes detection program, MOM will continue to make a huge impact on our community’s crushing unaddressed health crisis one patient at a time.

New Mexico Hispanic Medical Association

The New Mexico Hispanic Medical Association (NMHMA) is a private not-for-profit organization that has been in existence since 1989. Our mission is to make healthcare accessible and affordable to all New Mexicans. We do this by:

  • Offering affordable health care to the medically uninsured with the New Mexico Medical Card,
  • Encouraging and assisting citizens interested in pursuing a career in New Mexico healthcare,
  • Providing scholarships to students that have made a commitment to provide healthcare in New
  • Mexico,
  • Advocating for healthcare policy that increases access and affordability, and,
  • Providing charitable healthcare at community health fairs and other events,
  • Providing continuing medical education to health care professionals with an emphasis on conditions facing the medically uninsured and underserved

The NMHMA will play a major role in recruiting, identifying and serving the New Mexico Hispanic population through its outreach, marketing and referral processes.

The target population includes Medicare and Medicaid and uninsured patients of Hispanic ethnicity in Northern Arizona, Northern New Mexico and Las Cruces (Dona Ana County) New Mexico.

The elements included in this model are important to the overall expected impact of the model because the target population has historically been difficult to serve due to cultural and ethnic standards of the community.  This population has been continuously underserved due to lack of medical care accessibility, lack of culturally sensitive medical professionals that serve the target population, and lack of culturally and ethnic education, advising and counseling available.  Since the target group is at moderate to high risk for severe diabetic disease complications, the model, if proven effective, would be highly suitable to other populations, settings and geographical areas that have the same or less level of diabetic beneficiaries.  The medical history, personal and familiar knowledge of the disease and its ramifications will be assessed for each participant.

  • 1 of every 9 people in Arizona had diabetes in 2009
  • In 2008, 9.883 hospitalizations in Arizona were due to diabetes, that is 27 hospitalizations each day in the state due to diabetes

Comprehensive data concerning the financial impact of diabetes specific to Arizona can only be estimated. The cost associated with hospitalization and emergency room utilization does not consider the outpatient charges. Estimates for direct medical cost were developed based on the 1997 ADA report entitled Economic consequences of diabetes mellitus in the United States.

These numbers were then adjusted with the Consumer Price Index to 2004 figures. The total cost of direct medical care for diabetes in Arizona during 2004 was $3 billion. Indirect (non-medical) costs such as present and future resources lost to individuals and families as a consequence of the disease, and the psychosocial costs such as the impact of diabetes on quality of life were not calculated.

The ADA estimates the annual medical expenditures per capita at $13,243 for people with diabetes and $2,560 for people without diabetes. Diabetes is a costly disease that poses a major public health problem. Much of the health and economic burden of diabetes can be averted through known prevention measures. Prevention of complications through patient education, covered supplies through insurance or AHCCCS, and improved clinical practice behaviors would cost only a fraction of the cost of being admitted to a hospital for care of these complications.

  • Approximately 1 in 11 adults in New Mexico had diabetes in 2012
  • Over 300,000 New Mexicans have diabetes
    • 2/3 of patients know they have diabetes
    • 1/3 of patients do not know they have diabetes
    • Of those with diagnosed diabetes, 5 to 10% have type 1; 90-95% have type 2
    • American Indians are about 3 times more likely to have diagnosed diabetes than non- Hispanic whites
    • Hispanics, as well as African-Americans are about 2 times more likely to have diagnosed diabetes than non-Hispanic whites

In New Mexico in 2012, diabetes was the 6th leading cause of death. Diabetes was the primary cause of 552 deaths. It was a contributing factor in an estimated additional 582 deaths. However, the numbers are an underestimation, as most patients with diabetes die from cardiovascular related diseases caused by poorly controlled diabetes.

The direct cost and indirect cost of diabetes in New Mexico in 2012, according to the American Diabetes Association, totaled over $1 billion.