National Diabetes Prevention Program in the Panhandle

State: NE Type: Promising Practice Year: 2014

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The goal of the National Diabetes Prevention Program in the Panhandle is to reduce the number of Nebraska Panhandle residents who develop type 2 diabetes and chronic illnesses through four primary objectives. Recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention. Identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program. Facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners; and develop a healthcare provider protocol that facilitates referrals into the program.

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Panhandle Public Health District
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National Diabetes Prevention Program in the Panhandle
Panhandle Public Health District is located in western Nebraska. PPHD’s population is 48,381 residents and covers over 13,250 square miles in the counties of Banner, Box Butte, Cheyenne, Dawes, Deuel, Garden, Kimball, Morrill, Sioux, and Sheridan Counties. These communities are classified as rural or frontier with some areas being declared food deserts.Diabetes is an epidemic that is significantly affecting the health and economy of the U.S. 1 in 9 adults have diabetes and 1 of 5 health care dollars is now spent caring for someone diagnosed with diabetes. CDC estimates that if current trends continue, as many as 1 in 3 Americans could develop diabetes in their lifetime. The current rate of adults in PPHD’s jurisdiction with diabetes is 6.8 compared to 8.3 nationally. Diabetes can lead to a variety of disabling and life threatening complications and it is the seventh leading cause of death in the U.S. It is the leading cause of kidney failure, non-traumatic lower-limb amputation, new cases of blindness and is a major cause of heart disease and stroke among adults in the U.S. The risk of death among people with diabetes is about twice that of people of similar age without diabetes. The overall cost of diabetes and its complications was estimated by CDC to be $174 billion in the U.S. in 2007 alone. Medical expenses for people with diabetes are more than two time higher than for people without diabetes. Prevention or delay of type 2 diabetes will save lives and money. The Diabetes Prevention Program (DPP), a large prevention study of people at high risk for diabetes, showed that lifestyle intervention to lose weight and increase physical activity reduced the development of type 2 diabetes by 58% during a 3-year period. The reduction was even greater, 71%, among adults aged 60 years or older. The goal of the National Diabetes Prevention Program in the Panhandle is to reduce the number of Nebraska Panhandle residents who develop type 2 diabetes and chronic illnesses through four primary objectives. Recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention. Identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program. Facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners; and develop a healthcare provider protocol that facilitates referrals into the program. This practice was implemented by Panhandle Public Health District who employees the program coordinator and contracts with organizations to assure there is capacity to offer the program throughout the Panhandle. These partners are charged with the task of identifying employees to be trained as lifestyle coaches, to offer the Diabetes Prevention Program, assist in collaborating with local healthcare providers to receive referrals, provide appropriate meeting space for the program and communicate successes, challenges and outcomes of proposed activities through emails and monthly conference calls with the program coordinator. All objectives have been met. There are thirty trained lifestyle coaches in ten partner organizations delivering the National Diabetes Prevention Program. There is a monthly conference call between the program coordinator and the coaches to share success, challenges and strategies to target people at risk for diabetes. About thirty news releases have been sent out to raise awareness about risk factors and the availability of the lifestyle change program. The forms and procedures for receiving referrals from clinical partners have been developed. PPHD staff and local lifestyle coaches have met with hospitals and clinics to raise awareness about the program and explain the referral process. The specific factors that led to the success of this practice is that it is coordinated at a regional level and is being rolled out the same way in each community. Classes are being held to a standard set by the CDC’s Diabetes Prevention Recognition Program. The program has had a positive impact on the health of the public. Since September 2012 there have been twenty community and five worksite wellness class series launched enrolling 253 participants from eleven counties totaling more than 2,400 classroom hours. In the four community classes that have completed the yearlong program, 33 individuals have lost 505 pounds, that’s an average of 15.3 pounds per person. Eighteen participants lost 7% of their body weight reducing their risk for diabetes by 58%. We compile success stories and have many that share how the program has changed lives.
Panhandle Public Health District serves ten rural and frontier counties located in western Nebraska. PPHD covers over 13,250 square miles and includes the counties of Banner, Box Butte, Cheyenne, Dawes, Deuel, Garden, Kimball, Morrill, Sioux, and Sheridan Counties. Some communities have been declared food deserts. Diabetes is an epidemic that has become increasingly common and is significantly affecting the health of Panhandle residents, making it one of the top public health issues in the Panhandle. In the Panhandle 9.1% of the residents (Including Scotts Bluff County) have been diagnosed with diabetes; this percentage is higher compared to 7% in Nebraska and 8.3% nationally. The first priority in our Community Health Improvement Plan is Healthy Living; defined through the MAPP Assessment as increased nutrition and increased exercise to reduce overweight and obesity, heart disease, cancer, diabetes, and many other health concerns. There is an estimated 450,000 Nebraskans aged 18 years or older with prediabetes. People who are overweight, physically inactive, have a family history of the disease or have prediabetes are at an increased risk of developing type 2 diabetes. Without interventions the number or Nebraskans with diabetes will continue to grow. During the past decade, diabetes has become increasingly common, both in Nebraska and throughout the United States. According to data collected in 2010 by the Behavioral Risk Factor Surveillance System (BRFSS), 7.6% of Nebraska residents 18 years of age or older have been diagnosed with diabetes, which is a significant increase from 4.9% recorded in 2000. These prevalence rates translate into an estimated 103,000 Nebraska adults with diabetes in 2010, compared to about 60,000 in 2000. BRFSS data from 2010 also indicate that there are more than 76,000 adults in Nebraska who have been diagnosed with prediabetes, although the total adult population with prediabetes, including diagnosed and undiagnosed cases, may be as high as 450,000. Two Healthy People 2020 national health targets addressed in the Panhandle’s Community Health Improvement Plan are also the leading two indicators to prevent or delay the onset of type 2 diabetes. 1) Increase the proportion of adults who engage in aerobic physical activity or at least moderate intensity for at least 150 minutes/week, or 75 minutes/week of vigorous intensity, or an equivalent combination to 47.9%. 2) To reduce the proportion of adults (age 20 and up) who are obese to 30.5 %. These indicators were determined as priorities through the MAPP Process. During the Assessment when asked “What do you think are the three most important ‘health problems’ in our community?” (problems that have the greatest impact on overall health) diabetes ranked 4th with 29.6%, falling short to cancers, aging and heart disease and stroke. The National Diabetes Prevention Program targets the 37.1% of Panhandle adults that are overweight and 29.1% obese and at risk for developing type 2 diabetes. People who are overweight, physically inactive, have a family history of the disease, had gestational diabetes, and/or are over the age of 45 would be considered at risk for developing type 2 diabetes. Diabetes also disproportionately affects minority populations and the elderly. Minority populations make up 14.7% of the Panhandle population and 5.5% of the Panhandle population is over 65 years of age.The target population is estimated at 35,000. The target population that has been reached is .7%. While this seems very small we need to remember that the target population is very inclusive, that prediabetes is a growing epidemic and the program has only been in the Panhandle for one year. In the course of one year National Diabetes Prevention Program has changed the lives of the 253 participants. We have also partnered with the Panhandle Worksite Wellness Council to connect the program with the businesses’ internal worksite wellness program. This has already been a successful method for reaching a greater number of individuals with the program. Prior to this effort, there has not been a coordinated effort to address prediabetes. The Panhandle’s 2012 Community Health Improvement Plan helps address the epidemic through environmental and worksite wellness initiatives. Some of these include farmer’s markets, community gardens, worksite wellness initiatives, walking trails and bike racks. The National Diabetes Prevention Program is an improvement because during the program, participants learn ways to incorporate healthy eating and physical activity into their daily lives and work toward two primary goals: lose 5-7% of starting body weight over the course of the program, and do at least 150 minutes of physical activity each week. Participants meet weekly for approximately 16 weeks, then monthly for the remainder of the year. During the program, participants keep track of their food intake and physical activity. Lifestyle coaches work with the group to overcome barriers to a healthy lifestyle, by identifying emotions and situations that can sabotage successful weight loss. The group process encourages participants to share strategies for dealing with challenging situations. The group classes focus on healthy eating, increased physical activity, weight loss, lifestyle change and stress reduction and coping skills. These benefits with the environmental and worksite wellness initiatives in place will cultivate lifestyle changes. The current practice is innovative for establishing a systematic approach for Panhandle wide access to the National Diabetes Prevention Program by first building capacity, and then by assuring that it is implemented with fidelity to the model. This has allowed for regional marketing and acceptance of the program. We only partnered with organizations that agreed to develop the capacity and infrastructure to deliver the evidence-based lifestyle change intervention. To look at it from a holistic perspective we strive to identify strategies to target people at risk for diabetes, work to raise awareness about risk factors and the availability of the lifestyle change program and facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners. We also developed a healthcare provider protocol or algorithm that facilitates referrals into the program. To round out our holistic approach we support and promote farmers markets, bountiful baskets, community gardens for fresh fruits and vegetables; bike rack availability and walking paths to promote physical activity; referring participants that smoke to 1-800-Quit-Now; letting participants know Fecal Occult Blood Test kits are available; and promoting participants to use their Employee Assistance Program or other community resources for additional coping skills for stress reduction. The National Diabetes Program is the CDC-led evidence-based lifestyle change program for preventing type 2 diabetes.
Nutrition, Physical Activity, and Obesity
The goal of the National Diabetes Prevention Program in the Panhandle is to reduce the number of Nebraska Panhandle residents who develop type 2 diabetes and chronic illnesses through four primary objectives. Recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention. Identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program. Facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners; and develop a healthcare provider protocol or algorithm that facilitates referrals into the program. The initial steps of implementing the program were internal. Panhandle Public Health District (PPHD) set up training for the lifestyle coaches and developed the contract. PPHD continues to work cooperatively with in the organization to keep the program running smoothly for all partners and coaches and continues to collaborate with partners and coaches to address challenges and new opportunities. PPHD worked with the Panhandle Partnership for Health and Human Services Training Academy and the Diabetes Training and Technical Assistance Center (DTTAC) to solidify training for the lifestyle coaches. The program was awarded funding for the training through the Training Academy with this additional funding we are able to maximize support to the local partners to get the program up and running by September 30, 2012. Partners were able to send staff free of charge to the 2 day training by DTTAC master trainers on June 26 and 27, 2012, in Bridgeport NE. PPHD developed the contract to outline what was expected of partners and what they could expect from PPHD. Expectations for the partners are as follows: Contractor will have staff trained by Diabetes Training and Technical Assistance Center (DTTAC) master trainers on June 26 and 27, 2012 in Bridgeport. Contractor will offer and begin at least one “National Diabetes Prevention Program” intervention in their community by November 30, 2012. Contractor will send all requested documentation to the Regional Lifestyle Program Coordinator at PPHD, taking the steps to fulfill the CDC Diabetes Prevention Recognition Program (DPRP). Contractor will work with PPHD to assist in collaborating with local healthcare providers to receive referrals to the “National Diabetes Prevention Program”. Contractor will assist PPHD in developing a healthcare provider protocol or algorithm that facilitates referrals into the “National Diabetes Prevention Program" by participating in a minimum of one conference call after the training in June. Contractor will provide appropriate meeting space for delivery of 16 core sessions and 6 post-core sessions. These expectations changed slightly in the second year as we had a system in place to receive referrals. Contractor will continue to offer the “National Diabetes Prevention Program” in their communities. Contractor will send all requested documentation monthly to the Regional Lifestyle Program Coordinator at PPHD, taking the steps to fulfill the CDC Diabetes Prevention Recognition Program (DPRP). Contractor will work with PPHD to assist in collaborating with local healthcare providers to receive referrals to the “National Diabetes Prevention Program”. Contractor will provide appropriate meeting space for delivery of 16 core sessions and 6 post-core sessions. Contractor will communicate with Regional Lifestyle Program Coordinator at PPHD, about successes, challenges and outcomes of proposed activities through emails and monthly conference calls. Expectations for PPHD, PPHD and the Nebraska Department of Health and Services will provide all materials needed for the “National Diabetes Prevention Program” interventions. PPHD will provide registration, travel and meals for the Contractor to have staff trained. Carpooling within counties is requested. PPHD will provide technical assistance and project support through the Regional Lifestyle Program Coordinator. PPHD will work to help insure that the Contractor is taking the necessary steps to fulfill the CDC Diabetes Prevention Recognition Program (DPRP). To recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention we were selective in what organizations we approached. One of our goals for this objective was to partner with organizations throughout the Panhandle so that each community in our district would be covered. To do this the program manager and the PPHD director met to determine who we should approach. The plan that came out of the meeting was to partner with local organizations that were already getting community aid dollars from the health district. This would be another avenue that they could embrace for community outreach. After reviewing the budget a number was decided on, we knew the contract would not cover all the costs of the class so it was very important the organizations mission had an aspect of community outreach/education. We then sent emails to the organizations introducing NDPP and setting up a time to discuss the opportunity further. After these meetings we had successfully convened a group of key partners and “gatekeeper” organizations who share an interest in reducing the burden of type 2 diabetes by developing a frame work for the delivery of the National Diabetes Prevention Program. These organizations were tasked with identifying employees to attend the training to become lifestyle coaches. Seventeen people were trained to be lifestyle coaches from eight organizations: two from the Chadron Native American Center based out of Dawes County; three from the Volunteers of America - Western Nebraska based out of Garden and Deuel Counties; two from Box Butte General Hospital based out of Box Butte County; one from Gordon Memorial Hospital based out of Sheridan County; one from Banner County Schools out of Banner County, two with Western Community Health Resources based out of Dawes and Sioux Counties; three from CAP-WN based out of Scotts Bluff County including three bilingual participants; two from Panhandle Public Health Distract based out of Box Butte and Morrill Counties and the program coordinator. Nine of the eleven Panhandle counties were covered. We continued to work with organizations in the other counties and since then have all eleven counties are covered. The delay was in part due to changes in hospital personnel and concerns with NDPP conflicting with their other diabetes programs. After seeing the success NDPP was having throughout the Panhandle we received phone calls and partnered with Sidney Rehabilitation and Wellness Clinic and Sidney Regional Medical Center to cover Cheyenne County and Kimball Health Services to cover Kimball County. Since the initial training PPHD has trained 13 additional lifestyle coaches, including two bilingual coaches. To identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program we held meetings with each of our partners individually and discussed what they felt would work in their community. Out of these meeting the consensus was that PPHD would send out news releases, one of the training introducing NDPP to the community and others as classes were starting, PPHD would develop promotional materials, and lifestyle coaches and/or PPHD staff would attend health fairs. The promotional materials included brochures, posters with tear off information, postcards and a “Know your risk for prediabetes” one page test, these are each personalized to the partner, available in Spanish and have the program coordinator and local lifestyle coaches contact information. The brochures and posters were created to raise awareness and are used in hospitals, clinics, libraries and businesses. The postcards are used to follow up with prediabetic patients and as reminders for post core classes. The test is used at health fairs and with businesses. Planning meetings were held with the local partners to determine the best methods to facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners and develop a healthcare provider protocol or algorithm that facilitates referrals into the program. Our partners are really the experts on their communities and during these meetings we discussed what was needed and how to make the process as simple as possible for physicians. It was decided that PPHD and the lifestyle coaches would go together to each of the hospitals and clinics to have meetings with the physicians to introduce the program, the lifestyle coaches and the paper work. Two forms were created; the Lifestyle Prevention Referral Form is used by physicians to refer prediabetic patients to the program and the HIPAA release form allows the physicians to send the form to the program coordinator and allows lifestyle coaches to request participants past lab work. The regional NDPP program has continued to grow during the past year with continued support to the lifestyle coaches provided by the regional coordinator at PPHD. NDPP in the Panhandle has partnered with the Panhandle Worksite Wellness Council (a partnership between PPHD and Scotts Bluff County Health Department) to offer the program to their members and works with the regional Panhandle Prevention Coalition to raise awareness of the program. PPHD facilitates the contracts with the business and the partner organization that will be doing the sessions. There are monthly conference calls for all lifestyle coaches to collaborate. On these calls we discuss successes, challenges, new ideas for recruitment and opportunities that are available. A couple of examples of opportunities might be the availability of FOBT kits to the participants, promoting 1-800-Quit-Now, or flu shots. PPHD is the hub for all data from participant agreements to monthly weight and activity minutes. Internally we work together to track contracts, screen participants, connect with businesses, answer questions, request supplies, send out news releases, send in data for recognition and log the data for the 20 sessions that have started over the past year. We manage these processes through spreadsheets, emails and meetings as needed. The National Diabetes Prevention Program in the Panhandle is selective in who can participate though the target population is very inclusive, prediabetes is a growing epidemic and the target population is 35,000. Participants must be over 18 and have prediabetes or be at risk for prediabetes. Participants can either be physician referred with a positive blood draw for prediabetes or be self-referred. Self-referrals can take the “Know your risk for prediabetes” test online, over the phone or in person. The test has seven questions and each question is worth so many points. A score over 9 points puts the participant at high risk for prediabetes and qualifies them for NDPP. The questions are: Are you a woman that has had a baby weighing more than 9 pounds at birth? Do you have a brother or sister with diabetes? Do you have a parent with diabetes? Find your height on the chart. Do you weigh as much as or more than the weight listed for your height? (This is anyone with a BMI over 24) Are you younger than 65 and get little or no exercise in a typical day? Are you between 45 and 64 years of age? Are you 65 years of age or older? The question “Are you 65 years of age or older?” is worth 9 points so anyone over 65 years of age qualifies for the program. The question “Are you between 45 and 64 years of age?” is worth 5 points and anyone with a body mass index (BMI) over 24 is worth 5 points, so anyone over 45 years of age with a BMI over 24 qualifies for the program. The National Diabetes Prevention Program is a year-long lifestyle change program. Participants meet weekly for approximately 16 weeks, then monthly for the remainder of the year. Classes start throughout the Panhandle many times a year. The coaches do not wait until the first classes has completed the year before staring another group. There have been many stakeholders involved in establishing this regional approach for NDPP. The partner agencies that agreed to training and provide personnel for the lifestyle coaches are Chadron Native American Center, Volunteers of America - Western Nebraska, Box Butte General Hospital, Gordon Memorial Hospital, Western Community Health Resources, Community Action Partnership –Western Nebraska, Banner County Schools, Sidney Rehabilitation and Wellness Clinic, Sidney Regional Medical Center, Kimball Health Services, and Regional West Medical Center. They have all played an active role in determining processes and next steps to assure success of the program. They also have committed to implement the program with fidelity to the model in their local areas. We have also partnered with these local businesses to offer NDPP as a part of their worksite wellness plan: Cheyenne County, TE Connectivity, Western Nebraska Community College, Northwest Community Action Partnership, Chadron Community Hospital, Gordon Memorial Hospital, Kimball Health Services, Cirrus House Inc., Cabela’s and Fred A. Lockwood and Co. PPHD fosters collaboration with community stakeholders by including them in the assessment and planning phases as well as opportunities for implementation and evaluation of programs. All of the local public health system partners participated in the design of the 2012 Community Health Improvement Plan and have identified common goals and evidence based strategies on proven methods for success. There is a strong collaborative culture in the Panhandle of Nebraska and is a strong behavioral norm for the local public health system partners. The start-up costs were the cost of the training, the contracts with our partners and staff time. PPHD was awarded $15,122 for the training through the Training Academy – this was noted as in-kind to the program. In the first six months we spent $7,039.51 on wages and benefits, $1,297.82 in travel expenses, $1,086.95 in office expenses, $722.47 in promotional materials and $20,000 in contracted services.
The goal of the National Diabetes Prevention Program in the Panhandle is to reduce the number of Nebraska Panhandle residents who develop type 2 diabetes and chronic illnesses through four primary objectives. Recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention. Identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program. Facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners; and develop a healthcare provider protocol or algorithm that facilitates referrals into the program.The initial steps of implementing the program were internal. PPHD set up training for the lifestyle coaches and developed the contract. PPHD used multi-faceted plan to achieve the goals and objectives. To recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention we partnered with local organizations with a mission that had an aspect of community outreach/education. These organizations were tasked with identifying employees to attend the training to become lifestyle coaches. To be sure that capacity was developed to reach minority populations we partnered with organizations with the capacity to deliver the class in Spanish and the Chadron Native American Center with outreach to the Native American community. To identify strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program we held meetings with each of our partners individually and discussed what they felt would work in their community. Out of these meeting the consensus was that PPHD would send out news releases, one of the training introducing NDPP to the community and others as classes were starting, PPHD would develop promotional materials, and lifestyle coaches and/or PPHD staff would attend health fairs. Planning meetings were held with the local partners to determine the best methods to facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners and develop a healthcare provider protocol or algorithm that facilitates referrals into the program. Our partners are really the experts on their communities and during these meetings we discussed what was needed and how to make the process as simple as possible for physicians. It was decided that PPHD and the lifestyle coaches would go together to each of the hospitals and clinics to have meetings with the physicians to introduce the program, the lifestyle coaches and the paper work. The regional NDPP program has continued to grow during the past year with continued support to the lifestyle coaches provided by the program coordinator at PPHD. NDPP has partnered with the Panhandle Worksite Wellness Council (a partnership between PPHD and Scotts Bluff County Health Department) to offer the program to their members and works with the regional Panhandle Prevention Coalition to raise awareness of the program. PPHD facilitates the contracts with the business and the partner organization that will be doing the sessions. There are monthly conference calls for all lifestyle coaches to collaborate. On these calls we discuss successes, challenges, new ideas for recruitment and opportunities that are available. PPHD is the hub for all data from participant agreements to monthly weight and activity minutes. Internally we work together to track contracts, screen participants, connect with businesses, answer questions, request supplies, send out news releases, send in data for recognition and log the data for the 20 sessions that have started over the past year. We manage these processes through spreadsheets, emails and meetings as needed.The process is evaluated continually and the program is evaluated quantitatively at the end of each year-long session and qualitative through anecdotal evidence throughout the entire process. To evaluate the process we look at our four objectives to be sure we are moving in the right direction and note the lessons learned. To recruit and train identified individuals within partner organizations with the capacity and infrastructure in place to deliver the evidence-based lifestyle change intervention we have continued to add partners and have no concerns or lessons learned for this objective. Our plan is working for identifying strategies targeting people at risk for diabetes in order to raise awareness about risk factors and the availability of the lifestyle change program, but it is also important to note that word of mouth has proven to be one of the best ways to recruit participants. Many are joining because of a friend, family member, coworker or acquaintance has had success with the program. The objective to facilitate relationships between partner organizations delivering the lifestyle change intervention and referring clinical partners and develop a healthcare provider protocol or algorithm that facilitates referrals into the program has been more challenging. While some physicians have the process down and make steady referrals others have lagged in referring participants to the program. At the year mark it was noted that it is time for the lifestyle coaches and/or the program coordinators to make contact with the local physicians and share the local data and success stories with them. The provider protocol is working well and we have no concerns or lessons to note. At the first session participants are weighed and fill out the Participant Demographics and Participant Agreement Forms. This information is our baseline data for evaluation. It is collected directly from the participant and sent to PPHD. Each week the lifestyle coach records who is present for thee session, weighs the participant and after week 5 records their activity minutes. This record of attendance and the participant’s final weight recorded is used for evaluation of the program. The program is evaluated on attendance, documentation of body weight and activity minutes, weight loss achieved, and program eligibility requirement. Our evaluation mirrors the requirements for CDC full recognition status. All data is based on all participants who attended at least four core sessions. The average number of core sessions attended by participants must be a minimum of nine. Body weight must have been recorded at 80% or more of all core sessions (including makeup sessions) attended by these participants. Physical activity minutes must have been recorded at 80% or more of all core sessions (including makeup sessions) attended by these participants. The average weight loss achieved over the entire intervention period by participants attending at least one post-core session must be a minimum of 5% of “starting” body weight. Minimum of 50% of participants must be eligible for the lifestyle intervention based on either a blood-based test indicating prediabetes or a history of gestational diabetes. The remainder must be eligible based on the CDC Prediabetes Screening Test. Results are analyzed in house and sent to the CDC recognition program. In the four locations that have completed the year-long program they have successfully meet the standards for attendance, documentation of body weight and activity minutes, and weight loss achieved. Two fall short on the program eligibility requirement with over 50 % eligible based on the CDC Prediabetes Screening Test. This is one area we have spent many hours weighing the pros and cons. At this point we do not turn people away so that we are able to meet this requirement. We do investigate to see if they have had a blood draw in the last year that puts them in the prediabetic range and recommend that they go in for a blood draw. At this point we have not made any modifications to the practice as a result of the data finding. We know that all of our participants are prediabetic, though over 50% are self-referred; we continue to strive to meet the program eligibility requirement standard. Qualitative data is collected through anecdotal evidence throughout the entire process. Participants and coaches have the opportunity to share success stories at any point. The following are quotes from the success stories: "The realistic weight loss goal set by the program and the weekly meetings with the lifestyle coach and group support has kept me accountable and focused. I have lost 23 pounds, exceeding the seven percent goal, in eight weeks! I still eat the foods I like, just have the tools and am aware of how portion sizes and exercise affect long term success. I have been a yo-yo dieter for years, but now, I am in control. I have more energy and the tools to reach my pre baby weight, after 20 years! I feel confident because of this program. My kids are also reaping the benefits, enjoying being active with me and eating more balanced." “My success story is not just in the area of weight loss but in the changing of my lifestyle. I went into this class thinking that I was going to lose all this weight in a record time and it was going to be like every other diet that I have tried. I would get excited at first and then when I stopped losing I would quit. This class is way more than I could have imagined. It didn’t start out by making me give up all these foods and put me on an exercise program that there was no way to complete on a daily basis. It has educated me on how to make good food choices. It gives me control over if I fail or succeed. It started with baby steps and has worked its way up. I now know how to fill a plate, count fat grams, how to eat out, do smart exercise, and most important I have learned how to keep myself on track. Our coach has showed us that we can use our daily tasks to get our exercise. She has shown us how to do things with a purpose not just for the sake of doing them. She has shown us how to define our “slips” so that we can win over them. This is what has helped me so much in taking this class. Learning self-control. I feel is my biggest success in this program. I am learning how to break my bad habits with food and make choices with a purpose. I am so glad that I have taken this class that has given me the tools I need to make true life change for not only me but for my family.” “As I reached my goals of weight loss lowering my triglycerides and cholesterol levels I was pleased to find that my chronic cough had all but ceased. I am happier and healthier since I’ve completed the core sessions and look forward to the upcoming post-core sessions.”
The lesson learned by PPHD in relation to the practice was that prediabetes affects almost every family and that there is a great need for intervention. We have learned the National Diabetes Prevention Program in the Panhandle works. It is lowering the rate of those in the Panhandle at risk for diabetes and other chronic illnesses. Not only is it positively affecting the participants it is affecting their families and coworkers.PPHD has learned that our partners are committed to continue collaborating with us in an effort to make the Panhandle healthier. We have been asked to train additional staff members at two locations, Western Community Health Resources and Box Butte General Hospital, so they were able to offer more classes and bilingual classes as the response for the program is so strong. Many communities have developed waiting lists. After seeing the success NDPP is having throughout the Panhandle we received phone calls and partnered with Sidney Rehabilitation and Wellness Clinic and Sidney Regional Medical Center to cover Cheyenne County and Kimball Health Services to cover Kimball County. Since the initial training PPHD has trained 13 additional lifestyle coaches, including two bilingual coaches. This practice is better than what has been done before because it adds a component that was missing and compliments other existing supports. In the past there has not been a program and the Panhandle has addressed the epidemic through environmental and worksite wellness initiatives. Some of these include farmer’s markets, community gardens, worksite wellness initiatives, walking trails and bike racks. NDPP works because it builds on all the initiatives that are in place. We did do a cost analysis.  For every dollar PPHD spent on NDPP in the Panhandle in the startup phase and the first year, resulted in $28 in benefits.  This number is estimated low.  We know people with diagnosed diabetes incur average medical expenditures of about $13,700 per year, of which about $7,900 is attributed to diabetes.  The benefit is calculating the $7900 attributed to diabetes by the 253 participants that have taken the class in the first year.  This cost analysis includes all PPHD expenses and does not include indirect costs acquired by our partners.    We were thinking about sustainability when we chose our partners. We knew the contract amount to them would not cover all the costs of the class so it was very important the organization’s mission have an aspect of community outreach/education. This mission along with the success of the program should lend itself to sustainability. This is our first year without grant funds and we continue to be able to fund our partners through discretionary funds. Support for the program has always been shared with our partners and is becoming imbedded into communities and worksite wellness programs. If needed in the future, we have the option to charge participants a nominal fee for the class. At this point it is offered at no cost to community participants and Panhandle Worksite Wellness Council members. PPHD is committed to the sustainability of the National Diabetes Prevention Program. The program coordinator’s job duties involve coordination of a number of programs and the portion of FTE for this is nominal and is being covered through discretionary funds. The program coordinator will continue to provide support for the lifestyle coaches, hold the program to the standards and provide evaluation of the ongoing classes. Materials are being provided through the Nebraska Department of Health and Human Services Nebraska Office of Women's and Men's Health and Diabetes Program.
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