Community-based models and long-term care

Thomas Jefferson University Thomas Jefferson University

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Department of Family & Community Medicine Faculty Papers Department of Family & Community Medicine

6-2012

Community-Based Partnerships for Improving Chronic Disease Community-Based Partnerships for Improving Chronic Disease Management Management

James Plumb Thomas Jefferson University

Laura Carson Weinsten Thomas Jefferson University

Rickie Brawer Thomas Jefferson University

Kevin Scott Thomas Jefferson University

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Recommended Citation Recommended Citation Plumb, James; Weinsten, Laura Carson; Brawer, Rickie; and Scott, Kevin, "Community-Based Partnerships for Improving Chronic Disease Management" (2012). Department of Family & Community Medicine Faculty Papers. Paper 29. https://jdc.jefferson.edu/fmfp/29

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1

Community-based Partnerships for Improving Chronic Disease Management

James Plumb, MD, MPH a,b

, Lara Carson Weinstein, MD, MPH c , Rickie Brawer PhD, MPH

d,e

Kevin Scott MD f

a Professor – Department of Family and Community Medicine, Jefferson Medical College of

Thomas Jefferson University

b Director – Center for Urban Health Thomas Jefferson University and Hospital

c Assistant Professor – Department of Family and Community Medicine, Jefferson Medical

College of Thomas Jefferson University

d Associate Director – Center for Urban Health – Thomas Jefferson University and Hospital

e Assistant Professor – Department of Family and Community Medicine, Jefferson Medical

College of Thomas Jefferson University

f Instructor – Department of Family and Community Medicine, Jefferson Medical College of

Thomas Jefferson University

The authors have nothing to disclose.

Keywords: chronic disease, community engagement, partnerships, chronic care model,

diabetes, refugee, homeless

2

ab Corresponding author for

c Co-author

d,e Co-author

proof and reprints:

James Plumb MD, MPH

Department of Family and

Community Medicine

Thomas Jefferson

University

1015 Chestnut– Suite 617

Philadelphia, PA 19107

(215)955-6340

(215)955-7529(fax)

[email protected]

Lara Weinstein MD, MPH

Department of Family and

Community Medicine

Thomas Jefferson

University

1015 Walnut – Suite 401

Philadelphia, PA 19107

(215)955-8363

(215)955-7529(fax)

lara.weinstein@jefferson.

edu

Rickie Brawer PhD, MPH

Center for Urban Health

1015 Chestnut – Suite 617

Philadelphia, Pa 19107

215-955-2396

215-955-7529 (fax)

rickie.brawer@jeffersonhos

pital.org

3

f Co-author

Kevin C. Scott MD

Department of Family and

Community Medicine

Thomas Jefferson

University

1015 Walnut – Suite 401

Philadelphia, PA 19107

(215)955-6340

(215)955-7529(fax)

[email protected]

Community-Based Partnerships for Improving Chronic Disease Management

Synopsis

With the growing burden of chronic disease, the medical and public health communities

are reexamining their roles and opportunities for more effective prevention and clinical

4

interventions. The potential to significantly improve chronic disease prevention and impact

morbidity and mortality from chronic conditions is enhanced by adopting strategies that

incorporate a social ecology perspective, realigning the patient-physician relationship,

integrating population health perspectives into the chronic care model, and effectively engaging

communities using established principles of community engagement.

Introduction

Chronic diseases such as heart disease, cancer, hypertension, stroke, and diabetes now

account for 80% of deaths in the United States (US) and 75% of health care costs. 1 In 2005,

44% of all Americans had at least 1 chronic condition and 13% had 3 or more. By 2020, an

estimated 157 million US residents will have 1 chronic condition or more. 1 With this growing

burden of chronic disease, the medical and public health communities are reexamining their roles

and envisioning innovative partnership opportunities for more effective interventions for chronic

disease prevention and management at a population level.

The potential to significantly improve chronic disease prevention and impact morbidity

and mortality from chronic conditions is enhanced by adopting strategies that integrate

population health and social ecological perspectives into the chronic care model, realigning the

patient-physician relationship, and effectively engaging communities.

The Expanded Chronic Care Model

From a health care system perspective, the Chronic Care Model (CCM), as developed

originally by Wagner, 2 identifies the essential elements that encourage high-quality care for

individuals suffering from chronic disease. These elements are the health system, self

5

management support, delivery system design, decision support, clinical information systems, and

the individuals’ communities. This Model was later refined to incorporate more specific concepts

in each of the above six elements – patient safety in health systems, cultural competency and

care management in delivery system design, care coordination in health system and clinical

information systems, and an emphasis on leveraging community policies and community

resources to address individual needs and care goals.

Because the CCM is geared to clinically oriented systems and difficult to use for broader

prevention and health promotion practices, Barr and colleagues 3 proposed the Expanded Chronic

Care Model (ECCM) in 2003 to include elements of the population health promotion field so that

broadly-based prevention efforts, recognition of the social determinants of health, and enhanced

community participation could also be integrated into the work of health system teams as they

seek to address chronic disease issues. The ECCM includes three additional components in

terms of community resources and policies. These include: building healthy public policy,

creating supportive environments, and strengthening community action. 3 These interrelated

components and relationships are shown in FIGURE 1

The ECCM represents a shift from primary- and hospital-based care focused on illness

and disability to community-oriented services that focus on the prevention of illness and

disability before they have a chance to occur. This shift is a vital aspect of responsible and

accountable healthcare management in today’s climate of healthcare reform with a strong

emphasis on ensuring that community members are involved in planning for new services. 3

Realigning the Patient-Physician Relationship

6

Because chronic disease management is complex, it also requires a new view of the

patient-provider relationship in addition to enhanced community-based partnerships.

Collaborative care is a partnership paradigm that credits patients with an expertise that is similar

in importance to the expertise of professionals. 4

According to Holman and Loring, health care can be delivered more effectively and

efficiently if patients are full partners in the process. When acute disease was the primary cause

of illness, patients were generally inexperienced and passive recipients of medical care,

particularly since longitudinal follow-up was not required for these episodes. Now that chronic

disease has become the principal medical problem for so many, patients must become partners in

the care process, contributing their knowledge, preferences, and personal/social contexts at each

decision or action level. 5

Rationale for Community Partnerships in Chronic Disease Management

Chronic conditions are rooted not only in physiological processes, but also in socio-

cultural and political contexts. However, medical providers and programs primarily consider

chronic conditions at the individual or intrapersonal level. Chronic conditions are difficult to

manage, much less “cure,” through a series of disconnected interventions such as brief office

visits, public health announcements, government funded programs, individual service programs

or the establishment of community advocacy groups. A more comprehensive approach to address

root determinants of these chronic conditions is required, one involving community engagement

in defining the problem and developing partnerships to identify and implement effective and

sustainable solutions and management strategies

7

According to Green and colleagues, 6 past public health efforts focused primarily on

communicable disease. However, chronic diseases exist within the context of a much wider

array of lifestyle and social circumstances, each of which impacts the cause and course of

disease. Thus, a comprehensive, multilevel, multi-partner approach is required to develop the

capacity to implement effective chronic illness prevention and health promotion programs that

link traditional healthcare and socio-environmental and political efforts. 6 The healthy

community model for the 21st century should bridge disease prevention and management efforts

that are often developed, implemented and evaluated in “silos.” It should also connect health

promotion and management efforts across chronic diseases that often share the same underlying

root causes of disease, such as smoking, overweight/obesity, and limited physical activity.

Social Ecology Theory and Community Partnerships

The Social Ecology Model 7 of health promotion provides an important framework for

integrating community partnerships and chronic disease management. According to social

ecology theory, the potential to change individual risk behavior is considered within the social

and cultural context in which it occurs. 8 The social ecology model describes several levels of

influence which are critically interrelated and which must be recognized and addressed to effect

positive health change, including: intrapersonal factors, interpersonal factors, institutional and

organizational factors, community factors, public policies and broader structural or social

factors. 7 Within the context of the Social Ecology Model, individuals, social support systems,

community organizations, informal networks, and public policy leaders must be engaged and

collaborate for successful health promotion and chronic disease management.

8

One example of the social ecology model is the Building Community Support for

Diabetes Care (BCS) of the Robert Wood Johnson Foundation. 9 The BCS required that projects

build community supports for diabetes care through clinic-community partnerships, by

addressing four key areas: 1) working with existing services, encouraging use of these services

and enhancing access to them; 2) working together to identify gaps and create new programs,

services, or policies that complement existing services; 3) providing leadership and a forum to

raise awareness about diabetes and create consumer demand for resources and supports; and 4)

providing a forum for community input and participation. 9 Examples of BCS interventions by

ecological level are found in Table 1.

Brownson et. al. 9 conclude that BCS projects using partnership approaches show promise

for building community support for diabetes care. Chronic illness care and patient self-

management for diabetes and other chronic conditions will benefit from continued support for

implementation and evaluation of partnerships to build community supports for self-

management.

Community Engagement and Community Capacity Building

According to the Centers for Disease Control and Prevention (CDC), 10

community

engagement is defined as the process of working collaboratively with groups of people who are

affiliated by geographic proximity, special interests, or similar situations with respect to issues

affecting their well- being. It is helpful to consider the concepts of “community” and “capacity

building” to help shape the community engagement process. First, the term, “community,” is a

complex and fluid concept that needs to be defined. Some useful factors to consider when

defining a community include: socioeconomics, demographics, health status indices, ethnic and

9

cultural characteristics, geographic boundaries, community norms, formal and informal power

and authority figures, stakeholders, communication patterns, and existing assets and resources. 3

Second, when considering a community collaborative approach to addressing specific

health concerns, it is important to also consider the process of “capacity building.” Capacity

building accounts for current resources available to a particular group as well as additional

knowledge, skills and resources that may need to be made available to community members in

order for them to participate in meaningful community engagement. Capacity building is more

complex and time consuming than approaching superficial community engagement in a manner

that simply seeks community “buy-in” to a predetermined intervention. However, the effort

spent on capacity building will be much more likely to ensure a viable program in the long run

(i.e., sustainability). For example, true capacity building in a coalition with diverse membership

whose focus is to address diabetes management and prevention might include: diabetes training

for community leaders and lay health workers; assistance with survey development; programs to

improve coalition members’ understanding of community based education; facilitating the

identification of community goals and potential strategies to achieve those goals; and

strengthening relationship networks with grant writing skills and with government program

planners and funders.

The CDC / Agency for Toxic Substances and Disease Registry (ATSDR) Committee for

Community Engagement 10

has developed and refined principles for community engagement that

incorporate key concepts to “assist public health professionals and community leaders interested

in engaging the community in health decision making and action.” These principles are

summarized in Table 2. The principles of engagement can be used by people in a range of roles,

from the program funder who needs to know how to support community engagement to the

10

researcher or community leader who needs hands-on, practical information on how to mobilize

the members of a community to partner in research initiatives.

Community Based Partnerships: Local and National Case Examples

Jefferson’s Department of Family and Community Medicine and Center for Urban Health

Thomas Jefferson University’s (TJU) Department of Family and Community Medicine

(DFCM) is focusing on delivering a new model of care, which provides state-of-the-art,

comprehensive primary care in a variety of settings, from community to hospital, and engages

communities in improving health indices. This new model of care, built on DFCM and TJU

Hospitals’ (TJUH) resources and well-established links to community partnerships, integrates the

best of family medicine, community, and public health principles and practice. The DFCM

faculty, fellows, residents and staff are committed to participating more actively in reducing

inequalities in health, creating environments supportive of health, strengthening community

action, building healthy public policy, and reorienting health services.

Jefferson’s Center for Urban Health (CUH), directed by a DFCM faculty member, builds

on the work of the DFCM and multiple TJUH community outreach activities. The mission of the

Center is to improve the health and well being of Philadelphia citizens throughout the lifespan by

marshalling the resources of TJUH, TJU and its DFCM, and partnering with community

organizations and neighborhoods. The Center’s goal is to improve the health status of

individuals and targeted communities and neighborhoods through a multi-faceted initiative, the

11

ARCHES Project, which focuses on six domains/themes including: 1) Access and Advocacy; 2)

Research, Evaluation, and Outcomes Measurement; 3) Community Partnerships and Outreach; 4)

Health Education, Screening and Prevention Programs; 5) Education of Health Professions

Students and Providers; and 6) Service Delivery Systems Innovation.

Through the ARCHES Project, the Center’s many partners include schools, homeless

shelters, senior centers, faith-based communities, and other broad-based collaborative efforts that

recognize neighborhood economic, social, and physical environments as underlying determinants

of health and disease. In addition, the Center undertakes more extensive assessments in

partnership with community-based organizations to create programs that reflect community

need, voice and culture. Projects are planned and evaluated individually based on established

baselines set from existing data; information gleaned from key stakeholders through interviews,

focus groups and surveys that address critical attitudes, beliefs, and behaviors; and assessment of

community assets/resources such as human, economic and social capital. Importantly, project

planning and evaluation are driven by community members rather than the Center, which

provides technical expertise, linkages, and other support throughout the ongoing iterative

processes.

Specifically, the Jefferson CUH facilitates academic-community partnerships by serving

as a bridge between TJU/TJUH and urban neighborhoods to improve health outcomes through

the following mechanisms: 1) facilitating collaborations around research, community projects,

program planning/implementation and evaluation; 2) strengthening the capacity of the

Philadelphia neighborhoods to address community identified needs; and 3) initiating and

monitoring sustainable, collaborative interventions.

12

Additional DFCM/CUH community partnerships are summarized in Table 3, including

the Center for Refugee Health, Jeff H.O.P.E, 11, 12

Wellness Center, Pathways to Housing 13-1715, 16

and the Stroke, Hypertension and Prostate Education Intervention Team. 18

The JOINED-UP

Program, Community Asthma Prevention Program of Philadelphia 19

and Healthy Eating Active

Living Convergence Partnership 20

are described in detail below to provide examples of

successful, community-driven local and national efforts. These programs illustrate the

opportunity to engage with communities and community organizations to enhance chronic

disease management. Without this engagement, vulnerable populations would not have the

advantage of chronic disease prevention, detection or management.

The Job Opportunity Investment Network Education on Diabetes in Urban Populations

(JOINED-UP) Project

The Job Opportunity Investment Network Education on Diabetes in Urban Populations

(JOINED-UP) was built on a partnership between CUH and the Philadelphia Federation of

Neighborhood Centers (FNC). 21

Founded in 1906, FNC is an umbrella organization for 15

community-based organizations, with deep roots in the community in the tradition of Jane

Adams’ Settlement House Movement. 21

The Federation’s member agencies provide services to

more than 100,000 children, adults and families per year and have developed relationships with

multiple generations of families. 21

JOINED-UP was a diabetes and obesity healthy lifestyle education program that was

embedded into a Green Jobs workforce development training program held at two FNC member

agencies that targeted low-skilled, low-resourced residents in Philadelphia. As part of the

comprehensive job training program, participants in the program were required to attend six

13

Healthy Lifestyle workshops that were based on principles of the chronic disease self

management model and that used a “patient” case study (whose attributes were created by

program participants) as a means to encourage sharing of real life experiences related to

incorporating healthier behaviors onto daily life. Participants met individually with a

professional health educator to review screening/survey results, discuss personal health concerns,

and create a personal action plan. Motivational Interviewing (MI) techniques guided this

discussion. A Certified Diabetes Educator (CDE) met individually with individuals whose

screening results indicated pre-diabetes and provided information about diabetes, as well as

suggestions for risk reduction. The CDE counseled diagnosed diabetics about managing diabetes

and preventing complications. A key component of the JOINED-UP program was facilitating

patient activation and linkage to primary care. This provided an opportunity to engage and

educate patients in a trusted setting to improve interaction between patients and their primary

care providers.

The JOINED-UP program exemplifies a community-hospital outreach partnership that

educated participants about diabetes prevention and control and linked them to community

resources including primary healthcare providers. The JOINED-UP project has resulted in a

number of successful outcomes, including: 1) Integrating a diabetes prevention and management

program into a workforce development program is a feasible and effective method of recruiting

and engaging African-American men in a disease self management program; 2) Directly linking

the management of one's health to attaining and retaining a job, enhances the motivation of

clients to better manage their chronic health conditions because they develop a clear

understanding that one must stay healthy to secure and keep a job; 3) Providing healthy lifestyle

education in a familiar community center rather than a healthcare facility helps to build trust

between health educators and other members of the healthcare team and their client partners.

14

“Going to where men are” is crucial to effective engagement; 4) Providing wrap-around services

(i.e., job training, transportation, child care, emergency assistance, housing assistance, etc.) in a

central location where disease self management programming and support are also delivered

helps keep clients engaged in the self management program as well as the job training program,

and allows clients to incorporate disease management into their day-to-day routines. This

strategy offers synergistic rather than merely additive benefit; 5) Recognizing the high

prevalence of pre-diabetes (44%) provides an opportunity to impact further progression of

disease in participants; and 6) providing healthy lifestyle education as part of a workforce

development program can be an important factor in improving the health of children and

families.

Community Asthma Prevention Program of Philadelphia

The Community Asthma Prevention Program of Philadelphia (CAPP) 19

provided

community-based education for asthmatic children; however, this community-driven

intervention was also designed to create community lay asthma experts who could sustain

prevention and disease management efforts.

The CAPP, based on the You Can Control Asthma©-validated curriculum developed by

Georgetown University, was initiated in Philadelphia in 1997 by the Children’s Hospital of

Philadelphia (CHOP) through a cooperative agreement with the U.S. Department of Health and

Human Services. 22

This program involved a collaborative of more than twenty community-

based organizations, including primary care providers, hospitals, health care insurers, faith-based

institutions, recreation centers, and schools, that combined science with community assets,

interests and preferences to address poorly controlled asthma among children. This evidence-

based, multi-faceted, comprehensive program included opportunities for parents/caregivers and

15

children to learn about asthma self-management and control, education for primary care

providers, and provided home visits conducted by trained lay-health-educators to assess

environmental triggers. Community involvement ensured that interventions were acceptable and

accessible to the community, as well as integrated with other community efforts related to

asthma management.

Educational programs for asthmatic children and their caregivers were held in community

sites such as schools, daycare centers and churches, and were taught by trained peer educators

including parents of asthmatic children as well as asthmatic teenagers and college students.

Students received free asthma devices such as peak flow meters, and mattress and pillow covers

to reduce environmental triggers. Overall more than 3,500 members of the community

contributed to and participated in the program over a four year period. 23

In a study of 267

participants, knowledge, quality of life and asthma control significantly improved compared to

pre-program measures. 23

Moreover and notably, these gains were retained for at least one

year. 23

In addition, workshops for school personnel were conducted for classroom teachers,

health and physical education teachers, coaches and school nurses to convey information about

asthma symptoms and treatment and the impact of asthma on school performance and

attendance.

Finally, CAPP and CHOP, through the Controlling Asthma in American Cities Project,

offered three levels of primary care provider education based on NHBLI guidelines and the

needs of practitioners and their staffs. Using a modified Physician Asthma Care Education

(PACE) curriculum, Level One focused on asthma knowledge and patient-provider

communication. Level Two facilitated practice system changes by creating physician and nurse

asthma champions in practices, integrating support from CAPP’s clinical coordinator through

16

monthly case discussions and teleconferences, and using an Asthma Toolbox and patient

education materials designed by literacy experts. In Level Three educational programs, quality

improvement methods were integrated into practices through site-specific interventions.

In order to build a more robust system of coordinated services, CAPP’s efforts have been

linked to other asthma education programs through the efforts of Philadelphia Allies Against

Asthma (PAAA). 24

The Child Asthma Link Line developed by PAAA connects asthmatic

children seen in Philadelphia’s pediatric Emergency Departments or referred by schools to

CAPP’s community and school based programs. The CAPP and PAAA programs demonstrate

how multi-sector community involvement helps to create realistic approaches to disease

management, reduce barriers to care, and reduce duplicative efforts by bridging and integrating

multiple existing efforts aimed at improving health outcomes and reducing health disparities,

thereby leveraging available community resources and assets.

Reducing or eliminating health disparities such as those seen with the burden of asthma

morbidity among different ethnic and racial groups remains a challenge. Primary care

interventions that are linked with community-based interventions that address family, social and

behavioral factors is essential in meeting this challenge. Comprehensive systematic approaches

that connect diverse community partners, raise awareness and knowledge about health concerns,

and support policies addressing fragmented systems that affect health including health insurance,

school systems, and housing are needed to support and improve on the results of traditional

primary care efforts. Current efforts to reduce obesity and its underlying root causes provide the

context for the final case study.

Healthy Eating Active Living Convergence Partnership

17

Obesity is a complex health issue, and as such, requires complex solutions that involve

diverse individuals and institutions across multiple levels of society and that leverage public-

private partnerships. More than one-third of adults and 17% of children in the United States are

obese. 25

Obesity is a risk factor for many health conditions including heart disease, stroke,

hypertension, Type 2 diabetes, some cancers, liver and gall bladder disease sleep apnea,

respiratory problems, osteoarthritis, fertility problems and mental health conditions. Like

asthma, obesity cannot be managed by interventions focused at the individual level alone.

Scientists, the medical community, government, schools, business and other community partners

must coordinate responses designed to reverse this growing epidemic. Efforts to reduce and

control obesity are currently being implemented at the local, state and national level and involve

partners who may have little or no tradition of working together on health issues. These non-

traditional partners include societal sectors such as food supply and distribution systems, school

food systems and policies, food outlets such as supermarkets and corner stores, health care,

urban planning and zoning departments, transportation, recreation and parks departments, and

community based organizations such as the YMCA, bicycle coalitions, neighborhood centers and

faith-based institutions among many others.

In 2006, a collaboration of funders (the California Endowment, Kaiser Permanente, the

Kresge Fundation, Nemours, the Robert Wood Johnson Foundation, and the W.K.Kellogg

Foundation) created the Healthy Eating Active Living Convergence Partnership. 20

These national

organizations were funding initiatives focused on healthy eating and active living as strategies to

address overweight and obesity and were interested in developing a more coordinated approach

for improving healthy food and physical activity norms and environments. The CDC provided

technical assistance and Policy Link, a national research and action institute devoted to economic

18

and social equity, served as the program director for the Healthy Eating Active Living

Convergence Partnership. The Prevention Institute, a non-profit organization that promotes and

advocates for policies, organizational practices, and collaborative efforts that improve health and

the quality of life, provides policy research, analysis and strategic support for the Healthy Eating

Active Living Convergence Partnership. The Convergence Partnership is committed to

promoting and leveraging work across multiple fields and sectors to advance knowledge,

resource-sharing, and policy and environmental change that will help build a national movement

towards healthy people in healthy places. The Healthy Eating Active Living Partnership

supports each partners’ efforts and seeks to build new internal and external relationships to build

synergy across multiple disciplines and to strengthen local, regional and national policy and

system change efforts that support fresh, local healthy food and safe places to play and be

active. 20

The Convergence Partnership has developed a 10-point vision to promote healthy

eating and active living. This vision is summarized in Table 4.: 20

Healthcare organizations and providers play an important role in reducing obesity.

Primary care providers need to adopt and implement standard practices for routine BMI

screening and counseling that supports healthier food choices and physical activity at every visit.

Hospitals and other healthcare employers need to set an example for other employers by

promoting physical activity such as taking the stairs and improving food choices in cafeterias and

vending machines. Primary care providers and hospitals should also support breastfeeding

initiation, duration and exclusivity, one of the five target areas identified by the CDC’s State-

Based Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases

(NPAO). 25

Finally, physicians and other health care providers can refer patients to community

19

organizations that promote healthy eating and physical activity, and can advocate for system and

policy changes that make healthy choices the easier choices for their patients.

Conclusion

With the growing burden of chronic disease, the medical and public health communities

are reexamining their roles and exploring opportunities for more effective prevention and clinical

interventions. There is growing recognition of the need to address the underlying root

causes/contributing factors that cross multiple chronic diseases and to integrate the “silos” in

which chronic diseases are addressed. A social ecology approach to chronic disease calls for the

development of new collaborations between the traditional medical system (outpatient

physicians, emergency care, and inpatient facilities) and economic development, housing,

zoning, and access to healthy and affordable food. As professionals and citizens 26

, providers can

become directly involved in providing technical expertise and/or advocating in a variety of ways

for changes in social polices that effect health 27

. The expanded chronic care model provides a

foundation to explore these expanded roles and to operationalize the social ecology approach.

The established principles of community engagement detail a methodology to work with

communities to organize a more comprehensive approach to chronic disease prevention and

management.

To improve chronic disease management, physicians and the health systems in which

they work need to understand the principles of community engagement and proactively join in

efforts underway in communities in which they serve. Multiple examples of community

engagement have been provided highlighting the impact that can be realized through

collaboration with agencies which interface with populations at levels that are not traditionally

20

“health” related. This impact has been most evident in improving chronic disease management

and outcomes in diabetes, asthma, obesity and hypertension.

Future directions for research include rigorous testing of the Expanded Chronic Care

Model from a cost-effectiveness perspective, mixed-method evaluation strategies that involve

community members, such as participatory action research, and evaluation of processes designed

to enhance coordination between community-based programs and health care providers through

data sharing and collaborative planning.

21

Table 1: Examples of BCS interventions by ecological level

Ecological Level BCS Interventions

Individual Diabetes education classes, supermarket tours, case management,

community walking maps, cooking demonstrations

Family, friends and peers Family diabetes curriculum, support groups, peer led education classes

Systems/organizations Office staff training to enhance capacity to support diabetes self-

management, physician prescription pads for referrals to walking clubs,

creation of health care performance goals

Community/Policy Advocacy training for project workers, securing indoor spaces for physical

activity, diabetes materials in public libraries, presentations to community

organizations to increase awareness of diabetes, improved selection of fresh

produce at local markets

22

Table 2: Principles of Community Engagement 10

Principle Key elements

Set Goals • Clarify the purposes/goals of the engagement effort

• Specify populations and/or communities

Study Community • Economic conditions

• Political structures

• Norms and values

• Demographic trends

• History

• Experience with engagement efforts

• Perceptions of those initiating the engagement activities

Build Trust • Establish relationships

• Work with the formal and informal leadership

• Seek commitment from community organizations and leaders

• Create processes for mobilizing the community

Encourage self-determination • Community self-determination is the responsibility and right of all people

• No external entity should assume that it can bestow on a community the power to act in its own self-interest

Establish partnerships • Equitable partnerships are necessary for success

Respect diversity • Utilize multiple engagement strategies

• Explicitly recognize cultural influences

Identify community assets and

develop capacity • View community structures as resources for change and action

• Provide experts and resources to assist with analysis, decision- making, and action

• Provide support to develop leadership training, meeting facilitation, skill building

Release control to the community • Include as many elements of a community as possible

23

• Adapt to meet changing needs and growth

Make a long-term commitment • Recognize different stages of development and Provide ongoing technical assistance

Table 3: Examples of Jefferson community partnerships facilitating chronic disease

management

Program Community Partners Description Outcomes Funding Sources

Jeff HOPE Salvation Army

Resources for Human

Development

Prevention Point

Acts of the Apostles II

Bethesda Project

• Jefferson Medical student outreach program

11

• Provides free health care, health education and social

advocacy services to homeless

or otherwise medically

underserved individuals

• 2000 visits per year • Screened 300 men

for CV disease, 12

colorectal cancer,

prostate cancer, and

hepatitis C

• Student fundraising

• TJUH contribution

• American Assoc. of

Medical Colleges

• Caring Community

grants

• TJUH Women’s

Board

• Civic Foundation

Wellness Center Project H.O.M.E.

Wellness Center

Ridge Avenue

Business Association

Women Against

Abuse

Pro-Act

Council for

Relationships

• Primary medical care, behavioral health care,

nutrition education,

rehabilitative services, case

management, and peer-led

health promotion.

• Direct linkage to supportive housing, neighborhood-based

affordable housing, economic

development, access to

employment opportunities;

adult and youth education

• 800 visits/year • Implementation of

diabetes registry

• Independence BlueCross

Foundation

• Medicaid Managed Care

Pathways to

Housing

Pathways to Housing-

PA

• Housing First model which ends chronic homelessness for

individuals with serious

mental illness 13, 14

• Scattered site permanent supportive housing

• Trans-disciplinary care management team

15

• Novel integrated care program

• Chronic disease registry

16

• Ongoing tracking of standard health

indicators

• Integrated health record

• Medication management and e-

• Housing: Philadelphia Office

of Supportive

Housing

• Intensive care management:

Philadelphia

Department of

Behavioral health

24

through a unique partnership

with the DFCM 17

prescribing

• On-site adult vaccines

Center for

Refugee Health

Nationalities Service

Center (NSC)

Lutheran Family and

Children’s Services

Hebrew Immigrant

Aid Society

• Partnership facilitates communication between the

resettlement agencies and

DFCM to assist refugees

navigate through the

healthcare system (labs,

imaging, specialists,

pharmacies, etc.)

• Since 2009, more than 700 refugees

have received

comprehensive

screening and

follow-up at DFCM

• Barra Foundation • Pennsylvania

Refugee

Coordination Center

SHAPE-IT

Stroke,

Hypertension and

Prostate

Evaluation and

Intervention Team

DFCM

Center for Urban

Health

Philadelphia

Department of Health

Health Promotion

Council

Community Partners

• Reduce the incidence of stroke and morbidity and mortality

from prostate cancer high risk

AA men

• Development of Project Advisory Council (PAC)

• Screening/education for 7,019 men in

high risk zip codes

• Targeted population inked to primary

care services

• Pennsylvania Department of

Health

25

Table 4 – Convergence Partnership Vision

Safe neighborhoods, communities, and buildings support physical activity as part of everyday

life;

Fresh, local and healthy food is available and affordable in all communities and neighborhoods;

Healthy foods and beverages are promoted in grocery and other food stores, restaurants, and

entertainment venues;

Schools offer and promote healthy foods and beverages to students;

Schools promote healthy physical activities and incorporate them throughout the day, including

before and after school;

Workplaces and employers offer and promote access to healthy foods and beverages and

opportunities for physical activity;

Health care organizations and providers promote healthy eating and active living in their own

institutional policies and in their clinical practices;

Government and the private sector support and promote healthy eating and active living

environments;

Organizations, institutions and individuals that influence the information and entertainment

environments share responsibility for and act responsible to promote healthy eating and active

living

Childcare organizations, including preschool, afterschool and early childhood settings, offer and

promote only healthy foods and beverages to children and provide sufficient opportunities for,

26

and promote physical activity

Adapted From: Barr, V., Robinson, S.,Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., &

Salivaras, S. (2003). The Expanded Chronic Care Model: An Integration of Concepts and Strategies

from Population Health Promotion and the Chronic Care Model. Hospital

Quarterly, 7(1), 73-

82.

Community

Health System

Information

Systems

Decision

Support Delivery

System

Redesign

Self

Management

Build Healthy

Policy

Create

Supportive

Environment

Strengthen

Community

Action

Productive Interactions and

Continuous Relationships Activated

Patient

Activated

Community

Activated

Team

Proactive

Community

27

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