Chronic Disease Prevention and Management: Place-Based Strategies

State: OK Type: Model Practice Year: 2016

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The innovative practice focuses on improving the health outcomes for residents in our most disparate health ZIP codes; this includes communities with high concentration of African Americans and Hispanics.  Each component of the practice focuses on a different intervention area that collectively addresses systems, environment and behavior.  The approach aggregates successful programmatic best practices including the Chronic Disease Prevention and Management (My Heart) and Lifestyle Interventions (Total Wellness) in the target communities in order to engage multiple generations at multiple sites common to the communities. 

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Oklahoma City-County Health Department
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Chronic Disease Prevention and Management: Place-Based Strategies
The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents.  Oklahoma City and County are diverse communities, with more than one-fourth of the population representing a minority group (28%).  The largest ethnic minority is Hispanic (16%), equal to the current African American population.  Nearly one-third of the community population is 18 years old or younger (32.4%).  In 2013, the United Health Foundation ranked Oklahoma 44th in overall health, an improvement from 46th in 2012.  Oklahoma ranked 45th in the nation for obesity, 44th for physical inactivity, 42nd for poor physical health days,46th in fruit consumption, 42nd for youth obesity (2012 measure), and 41st in vegetable consumption.   Physical Activity In Oklahoma County only 45% of residents get the recommended 150 minutes of moderate activity per week.  Statewide physical activity is lowest among Hispanic adults (37%) and highest among African Americans (47%). Nutrition Oklahoma ranks 46th for fruit consumption and 41st for vegetable consumption according to the 2013 United Health Foundation, American Health Rankings.  According to a Gallup Poll conducted in 2013, 28% of Oklahoma County adults consume the recommended amount of fruits and/or vegetables.  Only 14% of youth report they meet this recommendation.  In Oklahoma County, only 32% of the population is classified as normal weight. Chronic Disease/Access to Health Care The United Health Foundation, American Health Ranking (2013) has ranked Oklahoma 48th in the nation for cardiovascular disease.  Both African Americans and Hispanics are less likely than other races and ethnicities to have their blood cholesterol assessed for risk (65% and 50%, respectively).  In Oklahoma County, 34% of adults have been informed they have high blood pressure (SMART BRFSS, 2011).  African Americans are disproportionately represented in this risk factor (42%), while Hispanics are underrepresented (21%).  The overarching goal is to reduce disparities in health outcomes (10% reduction in overall mortality in our jurisdiction between 2010 and 2020).  Recent data analysis demonstrates between 2010 and 2012, OKC-County realized a 1.2% reduction in overall mortality rates, demonstrating that our strategies are effective at moving the community towards this goal.  Program specific goals and objectives for each strategy intervention include: My Heart Goal: provide chronic disease prevention and management tools to at least 200 clients annually for three years, beginning July 1, 2014. Objectives: (1) reduce obesity among all participants within 12 months (metric: 5% reduction in body weight), (2) improve clinical baseline measures within 12 months (metric: 5% improvement in blood pressure, blood glucose and lipid panels), (3) improve clients’ adherence to clinical appointments and prescribed medication(s) within 12 months (metric: 100% of clients attend scheduled appointments, 100% of clients report taking medication(s) as prescribed). Total Wellness Goal: improve the health of citizens in Oklahoma County by increasing awareness of healthy eating and physical activity. Objectives: (1) reduce obesity among at least 15% of participants (metric: 5% reduction in body weight in overweight/obese participants), (2) increase physical activity among at least 50% of participants (metric: 50% report 150 minutes of weekly physical activity), (3) increase awareness of nutritional intake by utilizing weekly food diaries (metric: 50% of participants complete a food diary at least 4 of the 8 weeks during the class session). My Heart participants are enrolled on a continuous basis designated by quarters. The first and second cohorts completed their 1 year participation in My Heart in the Summer and Fall seasons of 2015. The results from these cohorts (discussed in the evaluation section) demonstrate the impact these programs have on improving the health and wellness of citizens in Oklahoma County. Specific factors of success include: integrated and strategic delivery of program interventions derived from the evidence base and engaging partners and program implementation staff in program design.  The public health impact of this practice will be a reduction in disparities in health outcomes and improvement of county-wide health status.
The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents, but on weekdays, the population grows to an estimated 1.2 to 1.3 million as people from outlying counties come into Oklahoma County to work.  The residential population is approximately one-fifth of the total state population, but the commuter population brings that number closer to one-third of the state population.   Oklahoma City and County are diverse communities, with more than one-fourth of the population representing a minority group (28%).  The largest ethnic minority is Hispanic (16%), equal to the current African American population.  Our youth population has been expanding rapidly in recent years with nearly one-third of the community population 18 years old or younger (32.4%).  The growing youth population presents unique challenges to community infrastructure and planning.  Data illustrates there is reason to be concerned for the future of our young families with nearly one-fourth of children living in poverty (22%), one in three female headed households living in poverty (34%) and one in five children residing in single parent households (18%). The Wellness Now (WN) coalition has been an instrumental partnership to improve health outcomes, and since its inception, Oklahoma County has realized some important improvements in health outcomes, illustrated in the most recent release of the Wellness Score. The Wellness Score is updated every third year and released to the community at-large as a tool for directing and allocating resources utilizing place-based strategies according to greatest need internally at OCCHD as well as for our community partners and coalition members.  The first release in 2010 directed OCCHD resources to ZIP code 73111 and surrounding geography, a primarily African American community.  The 2014 release of the Wellness Score revealed an overall reduction in all causes of mortality by 1.2% (883.8 per 100,000 to 873.5 per 100,000, comparing 2008-09 AAR to 2010-12 AAR), and also revealed that ZIP code 73111 was no longer the poorest health outcome ZIP code.  Additional county wide reductions were observed in mortality rates for other common chronic conditions including Stroke (3.9%), Cardiovascular Disease (2.9%), Lung Cancer (3.5%), Breast Cancer (4.7%), and Prostate Cancer (6.8%).  The OCCHD cites the development and successful sustainment of the Wellness Now Coalition, its resources and dedicated partners, and the implementation of place-based strategies for the measurable improvements in select outcomes.  Since early 1990, Oklahoma has seen a trend of increasingly poor health outcomes, demonstrating a clear divergence from the rest of the country which at that time began to see improvements in lifespan and overall health and well-being.  In 2010, the trend of declining health outcomes slowed until we observed some measured improvement statewide in 2011, presumably from new grant dollars and funds coming into the state as well as targeted planning and strategy among health officials.  In 2012 and 2013 the first continued improvement in health rankings was demonstrated for Oklahoma since the trend for increased poor health outcomes began in the 90s.  In 2013, the United Health Foundation ranked Oklahoma 44th in overall health, an improvement from 46th in 2012.  When considering factors that directly impact rates of chronic disease morbidity and mortality, Oklahoma ranked 45th in the nation for obesity, 44th for physical inactivity, 42nd for poor physical health days, 46th in fruit consumption, 42nd for youth obesity (2012 measure), and 41st in vegetable consumption.   According to the United Health Foundation, there are a number of core measures that impact a community’s health outcomes.   Physical Activity Oklahoma County continues to lag behind national averages for physical activity with less than half (45%) of residents getting the recommended 150 minutes of moderate activity per week.  Nationally, over half of U.S. adults (52%) are achieving this objective (BRFSS, 2011).  While county specific data is not available for this measure, statewide physical activity is lowest among Hispanic adults (37%) and highest among African Americans (47%).  As with tobacco use, income is a significant predictor of physical activity, with only 40% of those earning less than$15,000 per year engaging in physical activity, while those earning greater than $50,000 are meeting the national average (52%), (BRFSS, 2011).  Similar trends are also observed for educational attainment with College Graduates in Oklahoma actually exceeding the national average (55%) while only 36% of those without a high school diploma achieve this objective.    Nutrition As a state, Oklahoma ranks 46th for fruit consumption and 41st for vegetable consumption according to the 2013 United Health Foundation, American Health Rankings (2013).  According to a Gallup Poll conducted in 2013, just over one-fourth (28%) of Oklahoma County adult consume the recommended amount of fruits and/or vegetables (5 or more servings, 4 days per week).  Youth are in a worse state with only 14% reporting they meet this recommendation.  Approximately 19% of African American youth and 20% of Hispanic youth meet the recommendation.  Oklahoma is the 6th most obese state in the nation according to Trust for America’s Health (2012).  In Oklahoma County, only one-third (32%) of the population is classified as normal weight.  The remaining population is categorized as overweight (35%) or obese (32%).  Obesity disproportionately impacts African Americans (46%) while Hispanics are slightly below the county at 31%.  As illustrated with tobacco use and physical activity, those with higher educational attainment tended to be less obese.  In a divergence from trends observed in other risk factors, those earning more (greater than $50,000) were actually more likely to be obese (38%) than those earning less than $15,000 (33%).    Chronic Disease/Access to Health Care It is unsurprising, given the statistics for tobacco use, physical activity and nutrition behaviors, that preventable chronic disease is a tremendous burden on our healthcare system in Oklahoma.  Cardiovascular disease, for example is one of the leading causes of death in Oklahoma, and the United Health Foundation, American Health Ranking (2013) confirms that with our ranking of 48th in the nation for cardiovascular disease.  Heart attacks are more common among low income residents as well as those without a high school education. Both African Americans and Hispanics are less likely than other races and ethnicities to have their blood cholesterol assessed for risk (65% and 50%, respectively).  High cholesterol appears to impact low income earners (49%) and those without a high school diploma (45%) at higher rates than higher income earners (37%) with a college degree (36%).  Blood pressure awareness serves as another cost effective opportunity to prevent onset of chronic disease, and in Oklahoma County, 34% of resident adults have been informed they have high blood pressure (SMART BRFSS, 2011). African Americans are disproportionately represented in this risk factor (42%), while Hispanics are underrepresented (21%); nearly one-half (44%) of low-income earners report high blood pressure.  It is possible that Hispanic populations are underrepresented as a result of obstructed access to primary care providers.    As a state, Oklahoma ranks 39th in the nation for uninsured residents (17.1%), in Oklahoma County this rate is closer to one in every four residents (23%) are uninsured.  Of the uninsured population, African Americans and Hispanics represent the highest uninsured racial and ethnic groups, combining for two-thirds of the total uninsured population in Oklahoma County, 28% and 48%, respectively (BRFSS 2012), a disproportionate share of the one-third of total population they represent for the community.  Social and economic indicators continue to follow the trend of other risk factors, with stark disparities noted for low income earners—42% uninsured as opposed to only 7% uninsured among those earning more than $50,000.  Educational Attainment follows with 46% of those without a high school diploma uninsured as compared to college graduates where only 8% are uninsured.  Target Population and Reach   The innovative practice focuses on improving the health outcomes for residents in our most disparate health ZIP codes; this includes communities with high concentration of African Americans and Hispanics (16% and 16%, respectively, of the total city-county population).  The target ZIP codes represent more than 50% of the county-wide minority populations within the LHD jurisdiction.   The technical package the OCCHD has implemented utilizes a multi-generational, multi-setting approach to improving health outcomes and includes school, community and clinical-based strategies.  Community-based strategies have reached over 5,500 residents since Total Wellness launched in 2010, and clinical strategies have reached nearly 300 residents since July 2014.   Background of Innovation Historically, the OCCHD has subscribed to the identification and implementation of existing evidence-based best practices to improve health outcomes for its jurisdiction.  These practices were consistently implemented according to guidelines, but largely without coordination across target populations.  Efforts have been operating in silos even within the LHD with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population.  The initiation of the Wellness Score, described previously, was the first opportunity for OCCHD to begin planning for implementation based on geographic needs, health disparity, and with an emphasis on upstream indicators of health outcomes.   While the data and information presented previously paints a fairly bleak picture for Oklahoma City and County residents, the OCCHD and WN Coalition have committed significant resources to leverage partnerships and develop a plan of action to direct community planning and implementation efforts aimed at developing systems and environmental improvements through the use of a technical package[8] approach to health systems improvement. Use of a technical package that focuses resources on a single goal is critical to the success of the proposed strategies.  Each component of the innovative practice focuses on a different intervention area that collectively addresses systems, environment and behavior.    The approach aggregates successful programmatic best practices including the Chronic Disease Prevention and Management (My Heart) and Lifestyle Interventions (Total Wellness) in the target communities in order to engage multiple generations at multiple sites common to the communities.  Programmatic activities are complemented by policy action undertaken by the Wellness Now Coalition which include school and worksite nutrition and physical activity policies, advocacy for built environment and infrastructure planning such as complete streets, and expansion of tobacco-free policies, including a targeted effort at tobacco-free multi-unit housing. In 2014, this approach was deemed as a promising practice and integrates clinical and community health workers (CHW’s), and concentrates resources in the areas of greatest need. Data collected during the initial year illustrates a successful model that leverages community resources, enhances community health and promotes health and wellness through a unique technical package.  As a major population center for the state of Oklahoma, this inevitably translates into improved health status for the state as a whole. The innovation represents a creative use of existing tools and practices found in the Guide to Community Preventive Services, MMWR Recommendations and Reports, and the United States Preventive Services Taskforce and includes the following elements, placed in targeted, disparate health outcome ZIP codes within the LHD jurisdiction: 1.                Comprehensive data collection, analysis and dissemination utilizing the Mobilizing for Action through Planning and Partnership Tool, conducted every third year by the LHD; 2.                Integration of Clinical, Mental and Public Health preventive services utilizing Community Health Workers (My Heart) for targeted recruitment into chronic disease prevention programs that integrate clinical preventive protocols for select morbidities (diabetes, hypertension, obesity) with mental, social and environmental preventive activities through case management; 3.                Lifestyle and behavior modification (Total Wellness) through an 8 week curricula adapted from the Stanford Chronic Disease Prevention Program and the CDC’s Diabetes Prevention Program; and 4.                Integration of Community Health Workers into the Total Wellness teaching areas to build trust and engage in lifestyle and behavior modification, in addition to clinical, mental and public health preventive services. 5.                Targeted nutrition, physical activity and tobacco policy implementation county-wide. 
The overarching goal of the innovation is to reduce disparities in health outcomes, and to improve county-wide health status through the implementation of evidence-based programming and policies utilizing place-based strategies.  The OCCHD seeks to improve overall mortality in our jurisdiction by 10% between 2010 and 2020.  Recent data analysis demonstrates between 2010 and 2012, OKC-County realized a 1.2% reduction in overall mortality rates, demonstrating that our strategies are effective at moving the community towards this goal.  Larger reductions in mortality for specific disease outcomes ranged from 2% to 7% reductions in that same timeframe.  Program specific goals for each strategy intervention include: Total Wellness Goal: improve the health of citizens in Oklahoma County by increasing awareness of healthy eating and physical activity. Objectives: (1) reduce obesity among at least 15% of participants (metric: 5% reduction in body weight), (2) increase physical activity among at least 50% of participants (metric: 50% report 150 minutes of weekly physical activity), (3) increase awareness of nutritional intake by utilizing weekly food diaries (metric: 50% of participants). My Heart Goal: provide chronic disease prevention and management tools to at least 200 clients annually for three years, beginning July 1, 2014. Objectives: (1) reduce obesity among all participants within 12 months (metric: 5% reduction in body weight), (2) improve clinical baseline measures within 12 months (metric: 5% improvement in blood pressure, blood glucose and lipid panels), (3) improve clients’ adherence to clinical appointments and prescribed medication(s) within 12 months (metric: 100% of clients attend scheduled appointments, 100% of CHW follow up for appointment tracking,  100% of clients report taking medication(s) as prescribed). Implementation Activities Innovation implementation activities occurred concurrently to assure multi-generational, multi-setting engagement.  The confluence of program strategies across a targeted geographic region was the overarching goal for successful execution of the innovation. Each program has been evaluated and re-designed in order to meet this goal, including robust evaluation protocols in support of continued process and program improvements.  Total Wellness is the longest running program within the technical package.  Due to results from a previous evaluation, this program was re-designed which condensed the program to an 8 week class, increasing access to classes through the cross-training of Community Health Workers as instructors and on-going development of a volunteer instructor database.  Total Wellness is adapted from the Stanford Chronic Disease Management Program and the CDC’s Diabetes Prevention Program, into an 8 week class that provides adult participants with the tools and resources to improve their health through behavior and lifestyle changes.  Classes are offered several times per year, and are provided by a combination of staff including Community Health Workers, Registered Dieticians, and Health Promotion Specialists.  Conversion of the program to a peer train-the-trainer model will enable expansion into targeted communities, utilizing recognized peers and mentors for parents within the targeted schools, and their communities at large, and is an integrated aspect of the long term sustainability plan for the program.  The program consistently enrolls classes to capacity, and frequently has waiting lists to attend.  The program is offered in multiple community-based settings including OCCHD sites, libraries, faith-based institutions, community centers, schools and university and college campuses throughout the community.  The OCCHD My Heart project began development early in 2011, with pilot implementation occurring later in the same year.  My Heart is a 12 month program that utilizes targeted case management and finding through Community Health Workers to identify members of the community at highest risk for developing cardiovascular disease.  The program combines lifestyle interventions (Total Wellness, described previously) with care coordination through the CHW and access to primary care and pharmacotherapy interventions as driven by standard medical protocols.  Continued development of the program has supported a fully integrated primary care, public health, mental health care clinic within the local health department at the NE Regional Health and Wellness Campus as well as temporary facilities in South Oklahoma City.  The program has been well received, with more than 320 clients from at-risk communities participating in the program.  Due to the success of the pilot year, My Heart target areas have been expanded beyond the initial seven zip codes- into all of the Oklahoma City area. Thus, reaching more at risk communities in South Oklahoma City and Northeast Oklahoma City.  The strategy of targeting resources to the communities in greatest need has previously resulted in overall community health improvements, and OCCHD and partners plan to continue utilizing this strategy for expanding successful programs and efforts.  My Heart implemented the CHW/Total Wellness modular curricula developed with Langston University, a historically black college with locations in central Oklahoma.  The CHW curricula was developed with funds from the Community Transformation grant, and implementation of curricula was a major component of the previously identified objectives for that grant.  Creating a combination CHW/Total Wellness is intended to enable community-wide access to valuable lifestyle programs.  A CHW program is currently in the pilot phase with local hospital systems to support coordinated care for patients without a usual source of care.  Patients without usual care are high risk for inappropriate utilization of emergency care for unmanaged chronic conditions that are otherwise preventable.  This pilot expansion is hoped to impact multiple hospital settings in order to contribute to the evidence-base of improving integration of public health and acute care health settings.   Criteria for Inclusion The pilot process required that inclusion in programs implemented as part of the innovative practice, residents must reside in selected ZIP codes within the OCCHD jurisdiction. These include zip codes with the largest disparities in health outcomes located in the Northeast and South Oklahoma City communities including schools and residents within ZIP codes: 73111, 73105, 73117, 73121, 73108, 73109, and 73119.  Each of these ZIP codes represents a majority minority population.  There has been measurable success in the selected zip codes during the first year of program implementation. As a result, the My Heart inclusion criteria was expanded to reach all of Oklahoma City. My Heart is limited by age and risk factor and requires participants to be between the ages of 25 and 60 and have at least two risk factors for chronic disease including obesity, blood glucose, blood pressure or cholesterol. Timeframe Programs included within the innovative practice have operated as independent programs in the OCCHD jurisdiction for a minimum of 3 years.  Programs were each evaluated within the last 18 months to determine opportunities for improvement in process or delivery of program elements.  Following independent evaluation, programs were re-designed in the spring of 2014.  These programs undertook re-structuring and additional resources will allocated based on the community health outcomes and demonstrated need.  Programs were integrated for strategic delivery prior to the close of the 2014 fiscal year (June 30, 2014).  Programs will operate for three years under the current model of integrated, place-based implementation, during which time a robust quantitative and qualitative evaluation has been planned to determine the cost benefit and efficacy of the innovation.  The details of evaluation are included later in this narrative. Stakeholders The entire strategy relies heavily on the direction and support of the broad-based, multi-sector coalition, Wellness Now.  A broad array of partners has supported efforts to allocate resources based on regional health disparities, and include: Regional Food Bank: Provides on-site diet specific food boxes to patients receiving care at the integrated community health clinic on OCCHD sites. Physical Activity & Nutrition Workgroup: A WN workgroup actively engaged in policy development to support and advocate for the implementation of tax-free produce days in Oklahoma City and other Oklahoma County based municipalities.  OU Physicians Community Health Clinics: Provides primary care services as an integrated component of chronic disease prevention efforts in the My Heart Project. North care Mental Health: Provides mental health services as an integrated component of chronic disease prevention efforts in the My Heart Project and is listed as a partner on the Health at School program menu to provide counseling, social services, and life skills groups. North Rock Pharmacy: Provides low or no cost prescriptions for clients enrolled in the My Heart project. Langston University: A historically black university in Oklahoma, Langston University is currently piloting a modular Community Health Worker training program that will be adaptable to varying traditional and non-traditional healthcare delivery systems.  Funding Funds to support the described innovative practice have been allocated as a combination of the OCCHD local tax levy base and periodic grant funds.  The OCCHD Wellness Now coalition benefited from three years of funding through the Center for Disease Control’s Community Transformation Grant (CTG) for a total of $2,150,112.  These funds supported the development of environmental and infrastructure needs to expand the reach and capacity of the OCCHD and its partners.  For examples, CTG funds directly supported the development and implementation of the Community Health Worker curriculum and incentives to recruit clients into the evaluation components of the My Heart project.  Additionally, funding is received from the Oklahoma Tobacco Settlement Endowment Trust (OK TSET) for a total $979,288 from fiscal year 2013 through fiscal year 2015 in support of physical activity and nutrition workgroup activities, and $1,237,876 over the same timeframe to support tobacco prevention.  OK TSET funds are specifically earmarked for the development and implementation of policy and systems approaches to health improvement.  The Wellness Now coalition utilized OK TSET funds to expand tobacco-free policies throughout the Oklahoma City and County communities, and to increase awareness and adoption of policies related to the built environment and physical activity and nutrition in the schools.  Additionally, OCCHD, with partners, seeks to identify opportunities to draw reimbursements through the traditional public and private insurance payor systems to legitimize public health integration into primary care prevention to expand successful integration of the CHW role.  
The OCCHD believes strongly that public health interventions should be implemented utilizing place-based strategies that employ a technical package. By targeting program expansion to areas with high disparity, the OCCHD is allocating resources to areas where the greatest improvement can be achieved in the shortest time frame.  Additionally, locally elected officials, constrained by term limits, push health officials to demonstrate return on investment in terms of 12 – 18 month cycles in order to effectively advocate for relevant policy and ordinance changes. Given these parameters, the evaluation efforts for this innovative practice were developed with the end in mind, and focus on considering cost-benefit, program efficacy and broad health outcomes collectively.  Evaluations for each component of the innovative practice have been developed to incorporate qualitative and quantitative analysis, and incorporate multiple checks through the course of implementation to allow for program adjustments.  The inclusion of program evaluation as a component of the program planning and development was purposeful and is considered an aspect of the innovative practice. My Heart and Total Wellness My Heart aims to achieve a continuous enrollment population of at least 200 participants in the active cohorts. Measurements will be obtained at baseline and on a quarterly basis for the entire year. Additionally, Total Wellness participant baseline metrics at recruitment and conclusion of the 8-week course will be collected. My Heart participants are encouraged to participate in Total Wellness. In order to support this dual-enrollment, CHW’s have been teaching Total Wellness in targeted zip codes and encourage their My Heart clients to attend their classes. My Heart cohorts are assigned based on enrollment dates into the program. Currently, Cohorts 1 and 2 have completed 12 months in the program, with cohorts 3-6 currently participating in the study/recruitment. Results: My Heart Cohorts 1 and 2 realized the following results at the completion of their one year:  Cohort 1: (Enrollment dates: 7/1/14-9/30/14): -Nearly a 7% decrease in Body Mass Index - Over 400% increase in physical activity -21% decrease in Tobacco use -More than an 8% decrease in average total cholesterol -9% decrease in TC/HDL Cohort 2 (Enrollment dates: 10/1/14-12/31/14) -7.1% decrease in overweight and obese BMI’s -13% decrease in Total Cholesterol and TC/HDL -12% decrease in glucose average -Zero utilization of emergency departments reported during the 4th quarter visit 8-week total wellness:                -32 course sessions were held from Summer 2014 through Spring 2015                -62.1% of graduates completed food diary at the end of the course                -66% of graduates decreased total cholesterol by at least 3% -64.5% of graduates with pre-identified high triglyceride (TRG) labs at baseline realized a 5% or greater decrease in their  fasting triglycerides by conclusion of the Total Wellness course -58.1% of graduates with pre-identified elevated blood sugar at baseline noticed a 5% or greater decrease in fasting blood sugar by week 8 of the Total Wellness program -12% of previously overweight/obese 8-week graduates reached the goal of at least 5% weight loss The evaluation design ensures the following: 1. Providers and CHWs are properly trained on protocol implementation and are able to implement the protocol in a consistent and uniform manner.2. Data collection is accurate and provided in a timely and consistent manner.3. Patients are informed regarding the 12-month follow up timeframe and agree to maintain up to date contact information with providers and/or community health workers.4. The program administrator and supervisors complete regular audits and quality assurance activities to ensure clients are not lost. The overall goal of the evaluation is to determine the efficacy of the My Heart Program, with the following aims: 1. Assess the effectiveness of CHWs as providers on patient adherence to clinical protocols and medical appointments 2. Estimate the financial impact of My Heart for private and/or public insurers to detect:             a. Changes in financial claims when compared over historical trends in 12 month increments; and      b. Reduction in patient mobility across insurers and providers measured by uninterrupted coverage and/or single primary         care/medical home over a 12- month time period.3. Understand the effect of integrated and coordinated care on maintenance and/or improvement of select CVD indicators   including:        a. Blood Pressure                b. Comprehensive Lipid Panel         c. Weight/BMIThe analysis plan will include descriptive statistics (i.e. frequency), and comparison over time using the differences among the before, and after clinical metrics to measure the changes in metrics defined in Section 3.2 (Paired T-Test).  To meet Aim 1 (assessing the effectiveness of CHWs), patient compliance in areas such as keeping appointments and adhering to will be estimated using logistic regression analyses. Compliance will be modeled as a function of working with a CHW, the primary variable of interest, participation in the wellness class, controlling for health status and socio-demographic characteristics. To meet Aim 2 (assessing financial impact), the cost estimates will be examined in a number of ways. The cost of My Heart program will be calculated for per sample member for each cohort and broken down by key program components. There are three program cost components for My Heart and Total Wellness participants: expenditures for program enrollment activities, including recruitment and completion of comprehensive intake assessment; expenditures for program components, including cost of CHWs and Total Wellness staff; and expenditures for health services, including primary care visits and associated lab work, pharmaceuticals, and emergency department visits. The total cost per My Heart member will be calculated by summing these three cost elements. For members that only participate in Total Wellness, and not My Heart, the expenditure for program components will be less than participants enrolled in My Heart and Total Wellness in that there are no costs associated with primary care office visits, lab work and pharmaceuticals. My Heart focuses on reducing Emergency Department visits related to heart disease and/or diabetes. So, capturing the change in emergency department utilization from baseline to completion of the one year program allows us to estimate cost savings for the local hospital systems. The cost analysis will focus on the three program cost components. These costs will reflect the 12-month period following the patient’s enrollment in the program. In addition, the analysis will distinguish between gross and net costs. Net costs are the difference between the gross cost for an average member participating in both Total Wellness and My Heart and the gross cost for an average member that participates in either My Heart but not Total Wellness or in Total Wellness in the absence of My Heart. To meet Aim 3, an analysis of variance (3-way MANCOVA) will be conducted to determine differences in risk factors (i.e., blood pressure, lipid panel, and BMI) across cohorts.  Clinical de-identified patient data will undergo trend analysis over-time to determine any reductions in overall risk factors. A longitudinal analysis of clients enrolled into the My Heart program will be conducted to determine variation in clinical measures across cohorts. 
The OCCHD and Wellness Now coalition is committed to developing and implementing strategies that have long term impact and sustainability for the community.  The integrated and strategic delivery of program interventions was critical to community-wide health improvement realized by Oklahoma City and Oklahoma County from 2010 through 2012.  The data produce from the first year of this innovative practice described in this applications reflects the lessons learned from previous efforts, and the development of the technical package that is implemented in the framework using a combination of training and technical assistance, policy implementation and health service delivery integration.  To maintain these strategies and the long term impact for improved health outcomes, Interventions must focus on multi-generational, and place-driven.  Engaging partners and program implementation staff in program design was critical not only to successful implementation but to program sustainability.  These efforts have been undertaken with the idea that effective change comes at the helm of a shift in the community's culture.  OCCHD and Wellness Now have been at the forefront of the effort in Oklahoma City and believe strongly that these efforts represent a model practice for the design, implementation and evaluation of public health practice.
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