National Diabetes Prevention Program in the Panhandle

State: NE Type: Model Practice Year: 2015

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The National Diabetes Prevention Program in the Panhandle is quickly becoming a norm to  Nebraska Panhandle residents.  There are over thirty lifestyle coaches trained to offer NDPP and classes are available in every community and at worksites for there employes as a part of there worksite wellness program.  The National Diabetes Prevention Program in the Panhandle was selected as a Promising Practice in 2014.

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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 covers approximately 14,000 square miles and just over 50,000 residents and includes 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 areas being declared food deserts.  Minority populations make up 14.7% of the population and 5.5% of the population is over 65 years of age.  The National Diabetes Prevention Program in the Panhandle was selected as a Promising Practice in 2014. 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. There is an estimated 79 million American adult’s age 20 years or older with prediabetes.  Two-thirds of Panhandle adults are overweight or obese.  CDC estimates that if current trends continue, as many as 1 in 3 Americans could develop diabetes in their lifetime.  Prevention or delay of type 2 diabetes will save lives and money and is feasible and cost effective.  The National Diabetes Prevention Program (NDPP) is an evidence based practice based off the Diabetes Prevention Program, a large prevention study of people at high risk for diabetes that showed lifestyle interventions 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 NDPP in the Panhandle is to reduce the number of Nebraska Panhandle residents who develop type 2 diabetes and chronic illnesses.  To achieve this goal PPHD employees the Regional Lifestyle Program Coordinator and contracts with organizations to assure there is capacity to offer the program to community members and at worksites throughout the Panhandle.  These partners are charged with the tasks of identifying employees to be trained as lifestyle coaches, to offer NDPP to community members and in worksites, assist in collaborating with local healthcare providers to receive referrals, provide appropriate meeting space for the program and communicate with Regional Lifestyle Program Coordinator at PPHD, about successes, challenges and outcomes of proposed activities through emails and monthly conference calls. To meet the objectives there are twenty-six active lifestyle coaches under partner organizations delivering the NDPP an evidence-based lifestyle change intervention, based off the DPP research study.   There is a monthly conference call between the Panhandle Lifestyle Program Coordinator and the trained lifestyle coaches to share success, challenges and strategies to target people at risk for diabetes.  A news releases is sent out about a month before the start of a new class and the week before to raise awareness about risk factors and the availability of the lifestyle change program in the panhandle.  The forms and procedures for receiving referrals from clinical partners have been developed and PPHD staff and local lifestyle coaches have met with hospitals and clinics throughout the Panhandle to raise awareness about the program and explain the referral process.   Meetings are underway to add referral to NDPP to electronic medical records.  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 in each community, each class is being held to a high standard set by the CDC’s Diabetes Prevention Recognition Program, businesses have been targeted to offer the classes to their employees through their worksite wellness programs.  NDPP in the Panhandle has had a positive impact on the health of the public.  The program has served participants from all 11 counties within the panhandle and conducted 20 community Diabetes Prevention Classes.  2,416 total classroom hours have been taught to the 179 community participants.  There has been an additional nine businesses contracted to offer the classes to their employees. Five locations have started the course, serving 74 participants.  The first classes started in September 2012 and run a full year.   The 33 individuals in the four community classes that have completed the yearlong program lost 505 pounds, that’s an average of 15.3 pounds per person.  18 participants lost 7% of their body weight reducing their risk for diabetes by 58 percent.   We compile success stories and have many that share how the program has changed their lives.  One participant, reached her 7% weight loss goal set in the program, but moreover was excited that her cholesterol dropped 40 points. She noted, “I nearly had to go on cholesterol reducing medication but am happy to report that I am now close to a normal range.” http://www.pphd.org, http://www.pphd.org/DPP.html  
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.  9.6% of Panhandle residents have been diagnosed with diabetes, this percentage is higher than Nebraska and the U.S. percentage.  The first priority in our Community Health Improvement Plan is Healthy Living; stated in 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 intervention the number of 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 pre-diabetes, although the total adult population with pre-diabetes, 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 30.6 %.  These areas were picked after completing the MAPP Assessment.  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 two-thirds of Panhandle adults that are overweight or obese and are at risk for developing type 2 diabetes. People who are overweight, physically inactive, have a family history of the disease, have had gestational diabetes, and/or are over the age of 45 have 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 population and 5.5% of the population is over 65 years of age.  The target population is estimated at 30,000. Of which 02% of the target population has been reached.  While this seems very small we need to remember that the target population is very inclusive, that prediabetes is a growing epidemic, the program has only been in the Panhandle for two years, and is a yearlong commitment.  Since it’s kick off in 2012 NDPP has changed the lives of the 476 participants.  We have also partnered with the Panhandle Worksite Wellness Council to connect the program with the businesses internal worksite wellness program.  This is already showing success at getting the program out to many more individuals. 47% of participants have taken a class through worksite wellness.  Previously there has not been a program in the Panhandle to address prediabetes.  The Panhandle has addressed the epidemic through environmental and worksite wellness initiatives.  Some of these include farmer’s markets, community gardens, healthy vending, healthy meeting guidelines, walking trails and bike racks. National Diabetes Prevention Program works because participants learn ways to incorporate healthy eating and physical activity into their daily lives and set two primary goals.  To lose 5-7% of their starting body weight over the course of the program and to 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 their success, and 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 in how we have set the National Diabetes Prevention Program in the Panhandle up for success throughout the entire Panhandle by looking at the program from a holistic perspective.  Not limiting it to only a few communities has allowed for regional media, acceptance of the program and the beginning of a social norm change.  We only partnered with organizations with the capacity and infrastructure in place 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; using bike racks and walking paths to get there physical activity minutes in; referring participants that smoke to 1-800-Quit-Now; letting participants know FOBT kits are available; and promoting participants to use their Employee Assistance Program if one is available and they are having difficulties with stress reduction and their coping skills. 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.  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.  Panhandle Public Health District (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 November 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.  Initial 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).  www.cdc.gov/diabetes/prevention/recognition.   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).  www.cdc.gov/diabetes/prevention/recognition.  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.  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).   The only change to the contract for 2013 was a stronger emphasis on working with clinics to strengthen referalls. 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 organization throughout the Panhandle so that each community in our district would be covered.  To do this the program manager and the PPHD director meet 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 successful convened a group of key partner organizations who share an interest in reducing the burden of type 2 diabetes in developing a frame work for the delivery of NDPP.  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 Duel Counties; two from Box Butte General Hospital based out of  Box Butte County; one from Gordon Memorial Hospital based out of Sheridan County;  two with Western Community Health Resources based out of Dawes and Sioux Counties; three from CAP-WN based out of Scottsbluff County including three bilingual participants, one based out of Banner County; 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 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, Kimball Health Services to cover Kimball County, Regional West Medical Center and Scotts Bluff County Health Department.  Since the initial training PPHD has trained 15 additional lifestyle coaches, including two who are bilingual. 2014 marks a review of the Regional Community Health Improvement Plan, all hospitals are involved in this review.  This process has drawn even more light on NDPP and what it is doing and can do for the communities.  Many hospitals have added NDPP to their strategies to address the healthy living priority.  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 coordinators information.  The brochures and posters were created to paper the community 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.  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 again we went to our partners.  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 also decided that PPHD and the lifestyle coaches should go 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 for this 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.  During the past two years the program has grown with PPHD a continual support for the lifestyle coaches.  NDPP has partnered with the Panhandle Worksite Wellness Council to offer the program to their members and works with the Panhandle Partnership 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 are FOBT kits to the participants, promoting 1-800-Quit-Now, or flu shots promotion. 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, assume responsibility for quality assurance functions, complete data checks internally, send in data for recognition and log the data for the 35 sessions that have started over the past year.  We manage these processes through spreadsheets, emails and meetings as needed.  NDPP is very inclusive, prediabetes is a growing epidemic and the target population is 30,000.  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 years of ages is worth 5 points, so anyone over 45 years of age with a BMI over 24 years of ages qualifies for the program.    The National Diabetes Prevention Program is a year-long lifestyle change program.  Participants meet weekly for 16 weeks, then monthly for the remainder of the year.  Classes start though out the Panhandle many times a year.  The coaches do not wait until the first classes has completed the year before staringing 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, Scotts Bluff County Health Department 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, Garden County Health Services, City of Sidney, Alliance Y, Regional West Medical Center, Platte Valley Bank,  and Fred A. Lockwood & 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 review of the CHIP in 2014 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 process is evaluated continually and the program is evaluated quantitatively every 6 months 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.  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 while our plan is working we note that the word of mouth is assisting in recruiting participants.  Many are joining because of a friend, family member, coworker or acquaintances success.  To increase worksite wellness participation and to steam line the need for NDPP in a business the NDPP pre diabetes screener has been integrated into the Panhandle Worksite Wellness Council (PWWC) assessments.   One in every 5 employees in the Panhandle are employed by a business that is a member of the PWWC.   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 not established it as routine.  We note that the lifestyle coaches and/or the program coordinator needs to make contact with the local physicians, share the local data and success stories with them about every 6 months.  We implemented this in 2013.  The provider protocol is working well and we have no concerns or lessons to note. In a survey regarding the process for businesses to offer NDPP to their employees it was determined that businesses are facing challenges in recruitment and promotion of NDPP in the work place.  They were also struggling to recruit all at risk employees.  It was then determined that the PPHD leadership team would look at NDPP in the worksites as there next QI project.  At the next leadership team the Aim statement, improve process for recruitment and promotion of National Diabetes Prevention Program within Panhandle businesses, was developed.  The statement will be measured by the response to the yearly survey and a focus group.   Increasing physical activity and improving nutrition are the two goals of NDPP.  These are also priority areas in our Community Health Improvement Plan.   We know that works sites are a key avenue for disseminating this program and we strive to increase participation and success rates in the Panhandle. Improving this process will increase referrals to NDPP. Base line date for evaluation is collected at the first session when participants are weighed and fill out the Participant Demographics and Participant Agreement Forms.  They are collected directly from the participant and sent to PPHD.  Each week the lifestyle coach records who is present for the 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 were analyzed in house and sent to the CDC recognition program.  In the four locations that have completed the year-long program they have successfully met 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 and on the monthly lifestyle coach calls.  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. She 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 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.” We have added resources, certificates of completion and weight check-ins to the process as a result of evaluating the program with the lifestyle coaches.  Resource guides have been developed for each community, participants that complete the class to the CDC attendance standards receive a certificate of completion and PPHD is following up with participants at 6 months, 1 year and 5 years as a tool to assist in accountability and to further program evaluation.  
We have learned 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.  We have 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 waiting lists.   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, Kimball Health Services to cover Kimball County and Scotts Bluff County Health Department and Regional West Medical Center to cover Scotts Bluff County.  Since the initial training PPHD has trained additional lifestyle coaches, including two bilingual coaches, to meet the need in the community,   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 would not cover all the costs of the class so it was very important the organizations mission have an aspect of community outreach/education.  This mission along with the success of the program lend itself to sustainability.  The CHIP has lead to sustainability of the program.  Hospitals have been adopting NDPP as one of their strategies.  The regional review of the CHIP has confirmed healthy living as a priority area.  PPHD is committed to the sustainability of the National Diabetes Prevention Program.  We did not receive funding after the first year to contract with our partners to continue offering NDPP in the communities. PPHD believes strongly in this program and the success it has received and uses discretionary funds to continue the minimal contracts.  PPHD knows that if we support the program for a couple years it will be imbedded into communities, worksite wellness programs and the regional CHIP.  PPHD will continue to accrue the costs of employing the program coordinator indefinitely to insure the fidelity of the program.  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.  NDPP is offered at no charge to community participants and to Panhandle Worksite Wellness Council members. This could be evaluated and we could look at charging participants a nominal fee for the class.  We do not need or want to go down this avenue at this point.   
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