• Identification of high-risk patients in the community – the “High-Risk Approach”

This effort will target uninsured community members aged 44 years and older. The intent is to get these adults enrolled into the existing diabetes management program at Gotham hospital. Most of the uninsured in the Bronx community aged 44 and older are more likely to have the complications of diabetes due to the chronic progression of the disease. As such, these adults are at a higher risk of developing diabetic retinopathy, neuropathy, stroke, heart failure and foot ulcers leading to amputation. The team anticipates that if these groups are not proactively identified, they will eventually end up in the emergency room at Gotham hospital. By law, the EMTALA act requires stabilization before discharge from the ED or hospital; not long term treatment. Gotham hospital will be required to treat these adults at no cost if they lack the resources to pay for the services, placing a significant burden on Gotham’s budget. When successfully implemented, this program will lead to significant reduction in the avoidable costs attributable to diabetes emergency care in Gotham hospital. The IDF program design will identify this group of uninsured adults by reaching out directly to them in their local communities through ‘community-based’ organized outreach programs. The local coordinator can effectively coordinate these programs in the community.

In the team’s IDF integrated program design for Gotham, local community coordinators selected from the various sociocultural groups in the Bronx will work as members of Gotham’s hospital diabetes management with the following job description: 1) Serve as a mediator between Gotham hospital diabetes management team and the underserved in the community;2) Organize recruitment seminars and other programs in partnership with Gotham hospital that will aid in drawing people with diabetes into Gotham’s diabetes disease management program. This will facilitate increased enrollment into the program; 3)Work in liaison with different religious and community leaders in organizing diabetes prevention and management seminars as well as other diabetes related activities in the communities;4) organize and distribute educational brochures on diabetes in places such as saloon, subways, sports events and other social events. 5)Communicate the most recent information on diabetes; its prevention and management to members of their communities; 6)Ensure patient compliance with all physicians’ instructions, including taking their medication properly, checking their blood pressure and checking their blood sugar levels regularly; 7)Work with patients to quit smoking and avoid other unhealthy life style choices; 8)Distribute “Act on Diabetes Now®(IDF,2013) brochures, pamphlets, diabetes goal planner card, medication punch cards, bracelets and tags. These are all deliverables that will be distributed to patients through community organized diabetes management recruitment programs; 9) Send text messages to diabetes patients to remind them to take their medications, [would this work for the Medicare population in this community? Texting? ] adhere to their exercise routine and avoid unhealthy food choice amongst other things; 10) deliver post discharge services to the patient. Hospitals will need to team up with the patient primary care physicians and other health care coordinators as well as the local coordinator who will be in contact with the patient post discharge. [Isn’t this what the Gotham (and other ) ACO structures do?] The role of these care coordinators is to discuss the side effect of the medication as well as the compliance with it and their diet as all these factors will significantly reduce the rate of readmission.

The team suggests that for the initial phase of the program, 10 local coordinators be employed by Gotham hospital. Five local coordinators for the Hispanic/Latino community which accounts for about 53.50% of the Bronx population, 3 local coordinators for the African-American community which accounts for about 30.10% of Bronx community, and 1 local coordinator each for the White and Asian communities which account for 10.9% and 3.40% of the Bronx community respectively (NYMCDOH, 2009). Each local coordinator will be responsible for approximately 10% of their racial group excluding the Asian local coordinator whom will be responsible for 3.4%. The rationale behind the recruitment of a local coordinator is that a patient is more likely to trust a person of their racial group and the local coordinator will relate to these patients in their local language. The local coordinator is also better able to educate patients in the language they under