Plan for diabetes California's - our work in diabetes
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A coordinated
plan to help guide
our work in diabetess
2003-2007
California’s
plan for diabetess
Developed by the Diabetes in California Task ForceTable of Contents Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ■ The impact of diabetes in California ■ Contributing factors to a growing trend ■ Gaps in diabetes care California’s Plan for Diabetes: 2003-2007. . . . . . . . . . . . . . . . . . . . . . . . . 6 ■ Plan roadmap ■ Data collection and measurement ■ Using the Plan Plan Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 ■ Goal 1: Increase access to care ■ Goal 2: Improve quality of care ■ Goal 3: Promote primary prevention ■ Goal 4: Guide public policy Call to Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
— John F. Kennedy
Summary recommended interventions,
and expected outcomes when the
interventions are implemented.
Diabetes, a serious disease and major
Importantly, we also suggested
public health problem, is sweeping
measurement or evaluation tools
the country. California has approxi-
that could be used to monitor
mately two million people with
progress and determine when we
diabetes and a growing number
have achieved our goals. When
with pre-diabetes. Many excellent
a draft of the Plan was complete,
programs and initiatives exist in
we posted it on the Internet and
California to address diabetes, but
took it on the road to gather input
with major budget challenges and
at ten community meetings held
an exploding epidemic, it is essential
in cities throughout California.
that we work together to coordinate
We wanted this five-year plan to be
efforts and leverage our impact on
realistic and achievable, and serve as
this devastating disease.
a useable guide for work in diabetes.
California’s Plan for Diabetes Therefore, we did not address every
(the Plan) was developed to help problem or concern in diabetes.
organizations in their work to combat
The Plan serves three primary pur-
diabetes. The Plan belongs to the
poses. First, it assists state and local
people of California, as we are all
organizations in meeting national
objectives for diabetes, as defined
“Diabetes is like a tsunami wave that by such initiatives as Healthy People
has been developing force and 2010 and the National Diabetes
Objectives established by the Centers
is crashing down on California.” for Disease Control and Prevention.
Second, the Plan is meant to guide
impacted by diabetes. Many
organizations in their chosen
people throughout the state con-
activities insofar as they address
tributed to the development of the
diabetes as a major health concern in
Plan. Initially, a multi-disciplinary
California. Finally, the Plan promotes
group came together to identify
collaboration between organizations
broad topics or goals needed to be
in order to strengthen their combined
achieved in diabetes. Within each
efforts in addressing diabetes.
goal we identified priority areas,
2Introduction compromise people’s quality of
life, affect their ability to contribute
to their communities and cost great
The impact of diabetes amounts to manage and treat.
in California Spending in the United States for
Diabetes Mellitus (diabetes) is a diabetes was over $100 billion in
prevalent and serious public health 1992, or $10,071 per person with
concern, which has grown so rapidly diabetes, compared to $2,699 per
in recent years that representatives person without diabetes6. California’s
of the federal government call the share of this cost was approximately
disease “a national epidemic1.” The $12 billion from all sources. Although
disease affects more than 17 million California’s estimate is enormous,
people nationwide, and approxi- it is probably a conservative one
mately two million people have because lost wages, productivity,
diabetes in the state of California2. nursing home care costs, and nonpre-
In the 1990s, the prevalence of type 2 scription drugs are not included. Each
diabetes in California increased by year there are over 300,000 diabetes-
33 percent overall, and 70 percent related hospitalizations in California,
among people in their 30s3. The total at an annual cost of $3.4 billion7.
number of people with diabetes in
California is expected to double by Contributing factors
the year 20204. to a growing trend
The two major forms of diabetes are
In addition to being the sixth leading called type 1 and type 2, and both
cause of death in the United States5, cause similar kinds of complications.
diabetes contributes to the serious Gestational Diabetes Mellitus (GDM)
effects of other conditions. Diabetes is also an important form of diabetes
is the leading cause of major medical with onset or first recognition during
problems, including adult blindness, pregnancy. GDM complicates
kidney failure, non-traumatic ampu- approximately 7 percent of all preg-
tation of the lower limbs, and is nancies in the United States and is
a significant contributor to heart a risk factor for later development
disease and stroke. Furthermore, of type 2 diabetes8. Type 1 diabetes
serious birth defects may occur in is caused by a failure of the pancreas
the offspring of mothers with dia- to make insulin due to autoimmune
betes. All of these complications destruction of the insulin producing
3beta cells and accounts for about 5- of diabetes that has until recently
9
10 percent of all cases . Those with been diagnosed primarily in adults.
type 1 diabetes must take insulin to Some recent reports indicate that
stay alive and perform multiple daily 8–45 percent of children with newly
blood glucose (sugar) tests to assist diagnosed diabetes have type 2 dia-
with treatment decisions. Type 2 betes12. These children are typically
diabetes, due to insulin resistance overweight, 10 years of age or older,
and relative insulin deficiency, a member of a high-risk ethnic
accounts for 90-95 percent of all group, and have a family history
cases. Risk increases with age, obesity of type 2 diabetes.
and a sedentary lifestyle. Weight
Diabetes affects some populations
reduction and physical activity have
disproportionately, including African
been shown to reduce the risk of
Americans, American Indians/
developing type 2 diabetes and to
Alaskan Natives, Asian and Pacific
slow its progression. But obesity, one
Islanders, Hispanics/Latinos, and the
of the leading health indicators for
elderly. With an aging population
and over half of the state composed
“Everyday we see the devastation that of high-risk ethnic populations,
diabetes causes. But others may not see it. it is not surprising that diabetes
is increasing rapidly in California.
Diabetes is not contagious nor is it always
Another trend is the growing
visible. It’s hard to convince people that population of people with Impaired
it’s serious, but it is.” Glucose Tolerance or Impaired
Fasting Glucose, now called “pre-
the Healthy People 2010 initiative, is diabetes,”who have higher than
a significant problem in our country, normal blood glucose (sugar) levels
with over half of the adult population and are expected to be diagnosed
considered overweight or obese . In10
with type 2 diabetes within a decade.
2000, 15 percent of children under After finding that 16 million
age 19 were considered obese, Americans between 40 and 74 years
compared to 4-6 percent in 1974 . 11
old have this newly defined type 2
diabetes precursor, federal health
As a result of this increase in obesity,
officials and the American Diabetes
more children and adolescents are
Association recently issued guidelines
developing type 2 diabetes—a form
4recommending increased screening is known to be
13
for pre-diabetes . Pre-diabetes can effective in dia-
lead to type 2 diabetes and increase betes care, and
the risk of developing heart disease the care that is
by 50 percent. However, lifestyle actually provided.
changes such as moderate physical
The reasons for
activity and a more nutritious diet,
this gap are
can lead to moderate weight loss and
multiple and
may delay or prevent the onset of
complex. They
type 2 diabetes, if the condition is
include: a frag-
detected early.
mented and
Gaps in diabetes care confusing health
Effective screening and treatment care delivery sys-
methods exist for diabetes, yet many tem; increasing
people do not receive appropriate numbers of unin-
care. In an effort to improve the sured and under-
quality of medical care and heighten insured Californians; limited public encourage populations to improve
the level of awareness regarding resources for diabetes treatment and their lifestyle choices. Our societal
basic health care requirements for prevention; overburdened primary influences do not support healthy
those with diabetes, the Diabetes care physicians who are expected to lifestyle changes. Many people work
Coalition of California, in collabora- deliver the majority of clinical man- long hours in sedentary jobs, live
tion with the California Diabetes agement; and lack of incentives to in areas that have limited physical
Prevention and Control Program, coordinate and improve systems of activity options, are surrounded by
issued Basic Guidelines for Diabetes care. Complicating the issue further unhealthy food choices, such as an
Care (www.caldiabetes.org). These is an increasingly obese and seden- overabundance of junk food and fast
evidence-based guidelines, which tary population, creating more stress food restaurants, and face a growing
serve as a framework for the on a system already failing to deliver acceptance of increased portion sizes.
development of diabetes care pro- effective care in many instances. Overcoming these environmental bar-
grams and strategies, are aimed at riers requires consistent commitment
In addition to challenges within
reducing the personal and societal and diligence, as well as valuable time
the health care system, providers
impact of diabetes. There is still and resources.
are now struggling to assist and
a gap nonetheless, between what
5California’s Plan for risk for, dia-
betes. The Plan
does not outline
Diabetes: 2003-2007 every possible
solution, but
Because diabetes is a large and primarily focuses on those interven-
complicated health problem, there tions that are practical, achievable,
is a need for a comprehensive action and realistic in the current California
plan that promotes and advocates health care environment.
for coordinated diabetes care in
While all populations are considered
California. Many organizations in
for interventions, this Plan gives
California are already doing excellent
special attention to high-risk ethnic
work in diabetes, yet these efforts
groups, overweight children and
frequently occur in isolation, with
adolescents, older adults and the
little interaction between other
economically disadvantaged. The
organizations that are doing similar
Plan is grounded in current evidence
or complementary work. California’s
when proposing specific interven-
Plan for Diabetes provides a frame-
tions, and proposes measurable
work for these organizations to
objectives and outcomes that can
mobilize around a single set of
be expected upon implementation.
common goals: to increase access
This report is written for many
“It is our duty to provide hope, types of entities, ranging from local
community based organizations
even though at times, (CBOs) to governmental agencies.
diabetes seems hopeless.” The important aim of this Plan is
the coordination of diabetes work
to care, improve the quality of care, among organizations, providing
enhance primary prevention and focus and promoting collaboration.
guide public policy for diabetes.
The goals were established by a task
Plan roadmap force composed of key agencies and
Just as diabetes affects multiple pop- organizations across the state that
ulations in myriad ways, there are have identified diabetes as a clinical
many interventions that can achieve or community priority. Community
improved health in those with, or at input was gathered through a series
6of meetings statewide, where local a sophisticated data collection of programs for high-risk populations,
organizations provided feedback on system, but this should not preclude and implementation of health
the Plan. In addition, the Plan was them from participating in outcomes improvement programs for persons
available on the Internet for public measurement. An infrastructure for with diabetes. To assist organizations,
comment. The goals defined through collecting, analyzing, and distributing the California Diabetes Prevention
these meetings were: accurate data to relevant stakeholders and Control Program is offering its
is absolutely essential in order to reporting tool (available at www.cal-
■ Access: Identify and reach a larger
number of Californians with, or at assess progress and make informed diabetes.org) to facilitate the process.
risk for, diabetes programmatic decisions. This tool can be used to report data
on all six key measures. Patient
■ Quality Care: Promote guidelines The California Diabetes Prevention
identifiers will not be collected and
and strategies to improve care and Control Program has created
delivery if desired, the submitting organiza-
a reporting tool to help meet
tion’s identity will not be disclosed.
■ Primary Prevention: Increase requirements in providing data
Data can of course be collected in
awareness, knowledge and action to the Centers for Disease Control
any clinical or program area, but the
regarding diabetes prevention and Prevention. The California
tool focuses on the six key measures.
■ Policy: Guide public policy related Diabetes Prevention and Control
We encourage you to report your
to diabetes Program gathers information across
data to the California Diabetes
six key measures (National Diabetes
Each goal is outlined below, including Prevention and Control Program
Objectives): foot exams, eye exams,
priority areas, proposed interventions, so it can be used in measuring
influenza and pneumococcal vac-
and the change that is expected upon California’s progress in meeting the
cines, A1C tests, reduction of health
implementation of interventions. National Diabetes Objectives.
disparities through implementation
A coordinated and integrated
approach to improving diabetes
care in California through the year
2007 is possible, and this Plan serves
as a guide for all to accomplish that
objective.
Data collection
and measurement
For most organizations, collecting
and analyzing data for diabetes
activities is an ongoing challenge.
It is understood that many organiza-
tions in the state do not have4. Select recommended interven-
tions from the Plan that support
priority areas. Select those that are
realistic and achievable for your
organization. Consider collabora-
tions with other organizations to
utilize outside resources and
expertise.
5. Identify leadership and
intended beneficiaries in your
community. Create and imple-
ment interventions that consider
the needs of your community,
as
well as utilize local leadership
Using the Plan 1. Review your organization’s
to further goals.
In order to accommodate the varying mission statement. Define or
resources and needs of organizations, reconfirm which areas are of the 6. Create infrastructure for
highest priority to your own measurement and data
the Plan offers a host of areas for
organization. collection. Using an internal
potential focus, as well as numerous
data collection system, and/or
proposed interventions to begin or 2. Identify those goals from the
the tool provided by California
continue work in those areas. It is Plan that are most in alignment
Diabetes Prevention and Control
with your organization’s mission.
understood that many entities are Program, collect appropriate
Within the relevant goals, select
already focusing their efforts in the data, collate it, and share the
priority areas for your organization,
defined priority areas, and instead data with the California Diabetes
assigning timeframes to specific
of taking on new program develop- Prevention and Control Program
activities for the years 2003-2007.
and other partners.
ment, will opt for more guidance
3. Contact other community
in aligning their work with other 7. Revisit progress on priority
organizations in order to review
California organizations. areas periodically and monitor
and discuss their own priority
outcomes, both internally, and
areas. Create a community-wide
This Plan was crafted with the under- with other organizations in the
plan to ensure that key priority
standing that most organizations community. Stay connected to
areas are covered and duplication
have limited time and resources. It community resources to ensure
of effort is reduced. Then institute
is recommended that you follow the delivering needed services.
a communication mechanism
next seven steps to maximize your for updating all organizations
organization’s efforts in incorporating on progress.
the Plan.
8diabetes and work towards the
elimination of disparities in health
care. More Californians with, or at
risk for, diabetes will be identified,
and gain access to appropriate
screening, treatment and education.
As a result, fewer complications
Critical tasks will result from inconsistent self-
For myriad reasons, many people management, and undiagnosed
with, and at risk for, diabetes do and under-treated diabetes.
not receive appropriate care. This
To measure these important changes
is particularly true in high-risk ethnic
use data sources such as: Behavioral
populations, children and adoles-
Risk Factor Surveillance Survey
cents, pregnant women, older adults
(BRFSS); California Health Interview
and the economically disadvantaged.
Survey (CHIS); California Cooperative
The table below summarizes the
Health Care Reporting Initiative
priority areas and recommended
(CCHRI); Bureau of Primary Health
interventions to identify and reach
Care (BPHC) Health Disparities
a larger number of Californians with,
Collaborative; U.S./Mexico Border
and at risk for, diabetes.
Diabetes Project; Medicare/MediCal;
Evidence of Change and local county data.
Successful implementation of this
goal will lead to increased access to
care for people with, or at risk for,
“We know that people with diabetes
do best with continuous care, but if they
only have seasonal health coverage,
the continuity of care is broken.”
9PRIORITY AREAS RECOMMENDED INTERVENTIONS EXPECTED OUTCOMES
1.A Identify specific ■ Use existing local and California data (i.e. ■ Increased use of local and state data to identify
populations within California Diabetes Prevention and Control underserved populations.
your own community Program County Fact Sheets) to find ■ Increased number of organizations collecting
or organization with underserved populations with, and at risk data.
increased diabetes for, diabetes.
prevalence or high- ■ Begin process for collecting data for diabetes
risk, and either poor if no local data exists.
or no access to care.
1.B Promote better ■ Perform community assessment (e.g. ■ Community assessments are conducted,
alignment of www.diabetestodayntc.org) to determine existing services, needs and gaps are identified.
services to needs, existing services and gaps in diabetes ■ Increased number of new and maintained
at both local and prevention and treatment to clearly define collaborative partnerships established with
state levels. population needs. Gaps may include community, state and national programs aimed
discontinuity of care, lack of culturally at reducing health disparities for high-risk
appropriate services, transportation/mobility diabetes populations.
barriers, and lack of services for high-risk
populations. ■ Increased use of self-management tools such
as the Diabetes Health Record card.
■ Create plan for addressing gaps using collabora-
tive approach and working with partners to ■ Chart transfer mechanisms for providers
prioritize and fulfill remaining needs. are created.
■ Encourage use of self-management tools, ■ Tracking registries are developed.
i.e., Diabetes Health Record card ■ Increased availability of culturally appropriate
(www.caldiabetes.org) for patients to track services.
their own medical care. ■ Programs throughout California plan and
■ Create mechanisms for doctors to transfer implement more targeted and effective
charts when patients change care provider. programs, based on the needs and populations
■ Create registry that tracks care when patients identified.
change plan or site of care.
■ Create services that are culturally appropriate.
1.C Promote broad ■ Educate clinicians and health care personnel ■ Increased number of clinicians and health care
reaching access to about diabetes risk factors, prevention, personnel educated.
diabetes services diagnosis and treatment. ■ Increased number of community health
and tests through ■ Promote community health workers workers recruited, hired and trained.
CBOs, health care participation in diabetes prevention and
facilities, social ■ Increased number of people can effectively
treatment programs. navigate through health care systems.
services and
community health ■ Publicize when, where and how to access
workers. diabetes services.
Table 1. Increasing Access to Care
10Goal 2: Improve Evidence of Change
Successful implementation of these
interventions will result in increased
quality of care system, provider and patient support
for early diagnosis and coordinated
Critical tasks care delivery strategies for diabetes
Although evidence demonstrates that care that match the cultural needs
there are effective means of deliver- of the population. There will be
ing appropriate diabetes interven- greater adoption of team-based
tions, many providers and patients approaches in clinical offices that
are unaware of them. These missed use care guidelines, including the
opportunities can be due to frag- use of self-management training,
mented health care systems, inade- and better integration of community
quate provider and patient training, resources as part of a total system
or simply to the choices of providers of care. Widespread use of coordinat-
and patients not to adhere to the ed care models will result in more
most effective treatment plans. The patients receiving effective care.
table below outlines the priority
To measure these important changes
areas in implementing guidelines and
use data sources such as: BRFSS;
strategies to improve care delivery,
CHIS; CCHRI; BPHC Health
with recommended interventions for
Disparities Collaborative;
each area. The table is separated into
U.S./Mexico Border Diabetes
three categories of interventions:
Project; Medicare/MediCal;
system, provider and patient.
and local county data.
“Developing treatment guidelines
was key. We’ve done that. Now we’ve
got to use them in health systems
to create change.”
11PRIORITY AREAS RECOMMENDED INTERVENTIONS EXPECTED OUTCOMES
System ■ Conduct projects to evaluate effectiveness of ■ Evaluation projects conducted for coordinated
interventions: coordinated delivery models of care. delivery models of care.
2.A Evaluate, critique ■ Create common measures across state to allow ■ Increased number of programs using
and disseminate cross-sectional and longitudinal evaluations of coordinated delivery models of care.
coordinated coordinated delivery models of care. ■ Increased number of providers aware of
delivery models for ■ Develop and support community coordinated care delivery models through
common California collaboratives to train and encourage providers web sites, community meetings and
systems of care, such to use coordinated delivery models of care. presentations attended.
as Individual Practice
Associations (IPAs), ■ Research, catalog and share information about ■ Increased number of trainings conducted for
Preferred Provider existing models of coordinated care via web health care professionals on coordinated care
Organizations (PPOs), sites, community meetings and presentations. delivery models.
large medical groups, (i.e. www.qualityhealth care.org and ■ Increased number of academic institutions
and community www.healthdisparities.net). incorporating training on coordinated care
clinics. ■ Conduct training and ongoing education on delivery models in curricula.
effective coordinated care delivery models for ■ Mechanism developed for care coordination
health care professionals. among providers.
■ Work with academic institutions to integrate ■ Increased number of people with diabetes
effective coordinated care delivery models as receiving recommended A1C tests, eye
a component of their training curricula. exams, foot exams, influenza and
■ Develop a mechanism to coordinate care pneumococcal vaccines.
among providers when patients change
medical providers.
Provider ■ Promote the importance of diabetes risk ■ Increased number of people whose risk factors
interventions: assessment and screening/diagnostic testing are assessed.
2.B Promote and in high-risk groups such as ethnic populations, ■ Increased number of people are referred for
support earlier and the elderly, pregnant women, school age diagnostic testing.
more frequent children and those who are overweight
or obese. ■ Increased frequency of diagnostic testing for
diabetes risk people at high-risk and 45 years or older.
assessment and ■ Promote the use of the American Diabetes
diagnostic testing. Association’s Risk Test (a paper risk
assessment tool) to identify high-risk
individuals (www.diabetes.org). Persons
identified to be at high-risk should be referred
for diagnostic testing.
■ Use alternate venues such as health fairs,
schools and work sites to identify persons
at risk for diabetes (Note: organizations using
finger stick testing as a screening method
must do so with a Clinical Laboratory
Improvement Amendments (CLIA) license,
www.cms.hhs.gov/clia). Those identified to be
at risk should be referred for diagnostic testing.
■ Conduct and track diabetes screening/
diagnostic testing within health care delivery
systems for those 45 years or older. For those
at high-risk, screening should be done more
frequently or at an earlier age.
(continued on next page)
Table 2. Improving Quality of Care
12PRIORITY AREAS RECOMMENDED INTERVENTIONS EXPECTED OUTCOMES
2.C Identify and ■ Recruit and train culturally competent health ■ Increased number of culturally competent
implement model care professionals. health care professionals.
strategies to ■ Promote the use of clinical practice guidelines ■ Increased number of providers trained and
address gaps in and education materials by providers in high- using clinical practice guidelines.
quality of care. need areas. Combine with guideline training
Gaps may include ■ Increased number of providers trained and
for providers as necessary, to increase using coordinated care delivery models.
lack of cultural knowledge of the essential diabetes tests
competency, clinical and exams. ■ Increased number of providers receiving
knowledge, or compensation for meeting diabetes
continuity of care. ■ Conduct trainings with providers on performance measures.
coordination of care strategies throughout
health care systems. ■ Increased number of persons with diabetes
receiving recommended A1C tests, eye exams,
■ Link to Integrated Health Care Association’s foot exams, influenza and pneumococcal
(IHA) Pay-for-Performance Initiative to vaccines.
promote diabetes tests/exams (www.iha.org).
2.D Promote a team- ■ Work with health plans, provider groups and ■ Increased number of health care delivery
based approach to other health delivery systems to deliver systems using a team-based approach to
diabetes care delivery messages and tools to enhance team-based diabetes care.
that includes: care and to promote appropriate testing and ■ Increased number of nurse educators and
■ People with treatment. community health workers linking individuals
diabetes and their ■ Utilize nurse educators based at schools or to health care systems and engaged with the
families school districts and community health workers health care team.
■ Health care to link individuals to health care systems. ■ Increased number of people with diabetes
administrators ■ Work with community groups, community receiving recommended A1C tests, eye exams,
■ Health care health workers, school personnel, people with foot exams, influenza and pneumococcal
providers diabetes and their families to understand the vaccines.
team concept and their role on the team.
■ Public health
educators
■ Community health
workers
■ School personnel
Patient ■ Encourage patients to use self-management ■ Increased use of self-management tools such
interventions: tools, i.e. Diabetes Health Record card as the Diabetes Health Record card.
2.E Empower (www.caldiabetes.org), to improve ■ Increased use of culturally and linguistically
people with communication with health care providers appropriate educational materials.
diabetes to during clinical encounters.
■ Increased number of patient trainings
participate actively ■ Distribute culturally specific educational on self-management.
in their care and materials at appropriate literacy levels about
communicate diabetes self-management. ■ Increased number of consumer groups
effectively with their promoting principles of active self-
■ Organize consumer groups consisting of management.
health care team. people with diabetes who will promote
principles of active self-care to others with ■ Increased number of non-medical sites
diabetes, i.e. Diabetes Consumer Action promoting self-management.
Groups (www.caldiabetes.org). ■ Increased number of people with diabetes
■ Utilize non-traditional sites such as schools, receiving recommended A1C tests, eye
work sites and faith-based organizations to exams, foot exams, influenza and
promote active self-management. pneumococcal vaccines.
13Goal 3: and risk factors, in particular the link
between obesity and type 2 diabetes.
Awareness will also increase around
Promote primary the steps needed to prevent type 2
diabetes, particularly among children
prevention and adolescents, their parents and
overweight individuals. Greater
Critical tasks awareness among providers will lead
With diabetes rates rapidly increasing, to clear and consistent prevention
a surge in obesity, and the recent messages in the clinical setting and
acknowledgement of pre-diabetes as the community. Greater participation
a health priority, there is a need for among community organizations
targeted primary prevention efforts. will encourage local policies that
The table below summarizes priority recognize risk factors for type 2 dia-
areas in increasing knowledge, betes, support healthy food choices
awareness and action around type 2 and provide physical activity pro-
diabetes prevention, with recom- grams in schools and communities.
mended interventions for each area.
To measure these important changes
Evidence of Change use data sources such as BRFSS and
Successful implementation of these CHIS. In addition, track media mes-
interventions will result in messages sages and campaigns, peer educators’
being broadly disseminated that activities, primary prevention meth-
describe how to prevent type 2 ods, and policy changes to improve
diabetes. There will be increased healthy food consumption and
awareness of diabetes prevention physical activity programs.
“There needs to be a paradigm shift
where healthy habits are rewarded
in our health systems instead of
reimbursements that only pay once
someone is sick.”
14PRIORITY AREAS RECOMMENDED INTERVENTIONS EXPECTED OUTCOMES
3.A Design/identify ■ Form partnerships to establish new or utilize ■ Increased number of partnerships formed
and implement existing programs that promote wellness, to address chronic disease/type 2 diabetes
diabetes prevention physical activity, weight control and healthy prevention.
activities that focus eating for people at risk for chronic diseases ■ Increased media coverage about type 2
on the link between including type 2 diabetes. Encourage use of diabetes prevention and its link with obesity.
obesity and these programs at work sites, schools,
diabetes, particularly community centers, etc. ■ Talking points developed and distributed on
targeting children and lifestyle modification, weight management,
■ Utilize general and ethnic media as well as healthy eating and physical activity.
overweight, high-risk community resources to present messages to
adults. the public about diabetes risk factors and
prevention.
■ Develop talking points for teachers, clergy
and parents to address issues of lifestyle
modification, weight management, healthy
eating and physical activity.
3.B Educate ■ Work with partner organizations involved ■ Increased number of projects implemented for
providers to adopt in nutrition and physical activity to promote persons at risk for diabetes that are aimed at
primary prevention simple, consistent messages that providers lifestyle modification, promotion of wellness,
practices with high- can use with high-risk patients and families. physical activity, healthy nutrition and weight
risk individuals. Incorporate behavior change methodology management.
into messages. ■ Increased number of provider champions and
■ Find community provider champions to serve easy-to-use tools.
as messengers; support through provision of ■ Increased number of diabetes prevention
easy-to-use tools (i.e. talking points for collaboratives.
provider-patient discussions about overweight,
sedentary lifestyle, and nutrition).
■ Develop and support diabetes prevention
collaboratives between communities and
health care delivery systems.
3.C Change ■ Participate in policy changes and efforts to ■ Increased number of successful policies made
community improve healthy food consumption and to support healthy food choices and physical
environment to physical activity programs in schools and activity programs in schools and communities.
support and promote communities. ■ Increased number of local partnerships created
primary prevention ■ Form partnerships with local agencies to assess encouraging community change to support
of type 2 diabetes. community environment and prioritize healthy lifestyles.
changes needed to support healthy lifestyles. ■ Increased number of choices for physical
activity and healthy food in neighborhoods,
schools and work sites.
Table 3. Primary Prevention
15Goal 4: Guide Evidence of Change
Successful implementation of these
interventions will result in sustained
public policy changes that support appropriate dia-
betes prevention and treatment and
Critical tasks discoveries that will lead to a cure.
Effective diabetes prevention and
To measure these important changes
treatment requires a shift in policies
use data sources such as BRFSS and
that support population based
CHIS. In addition, track enactment
improvements. Scientific advances
of legislation or policies that expand
that result in improved treatment
access to self-management training,
methods and cures require policies
funding, and research.
that further these discoveries. The
table below identifies the priority
areas in influencing public policy
around diabetes, with recommended
interventions for each area.
16PRIORITY AREAS RECOMMENDED INTERVENTIONS EXPECTED OUTCOMES
4.A Enhance ■ Collaborate locally to identify high-priority ■ Increased number of communities that
legislative and community issues and advocate for targeted have action plans to address legislation and
regulatory advocacy solutions. policy issues.
at state and at local ■ Target specific legislators and identify specific ■ Increased contact with policy makers
levels. action steps for policy interventions. and legislators.
■ Elicit testimonials, patient stories, and case ■ Increased number of people equipped
studies from organizations, and share with to testify.
policy-making bodies/committees. ■ Appropriate legislation and policies passed
■ Develop talking points for people affected and implemented.
by diabetes and support advocacy training ■ Increased number of legislators who receive
in the community. and acknowledge the Plan.
■ Request town hall meetings with elected
officials for implementing priority areas.
■ Use the Plan as a communication tool with
legislators and other key government leaders.
4.B Review, evaluate, ■ Review existing data on cost effectiveness/cost ■ More policies will be implemented to support
and report cost savings. effective prevention/treatment interventions
effectiveness/cost ■ Analyze data on diabetes costs using that are cost effective.
savings associated appropriate methodologies.
with effective
diabetes prevention ■ Disseminate diabetes cost information to
and treatment legislators and policy makers.
interventions.
4.C Convey the ■ Identify existing evidence for effective diabetes ■ Increased evidence for effective diabetes self-
impact of diabetes self-management training and conduct management training.
services, including additional outcomes research to prove the ■ Increased evidence for effective primary
self-management effectiveness of diabetes self-management prevention interventions.
training, and primary training.
prevention to ■ Increased reimbursement for diabetes
■ Identify existing evidence for primary self-management training.
legislators and prevention interventions and conduct
policy makers. additional research to test effectiveness ■ Funding established for methods of primary
of interventions and facilitate their prevention.
implementation.
■ Request town hall meetings with elected
officials to develop strategies for improving
federal and state reimbursement for diabetes
self-management training and prevention.
4.D Promote ■ Advocate for funding of research to cure ■ Increased funding for diabetes research
increased funding for type 1 diabetes. and programs.
diabetes research ■ Advocate for funding of statewide and local ■ Increased variety of funding streams that
and programs. diabetes treatment and prevention programs. support diabetes prevention and treatment
■ Formulate budget requests linked to specific programs.
tasks and expected outcomes from the Plan.
Table 4. Guiding Public Policy
17Call to Action 4. Share data with the California
Diabetes Prevention and Control
Program to better monitor
California’s Plan for Diabetes pro- diabetes in the state.
vides a framework for organizations
5. Foster viable collaborations and
to mobilize around a single set of
partnerships at all levels.
common goals: increase access to
care, improve the quality of care, We believe that your action in
enhance primary prevention and addressing diabetes for the next five
guide public policy for diabetes. years will make a notable difference
It will take your active involvement in the lives of those with, or at risk
to assure that your community is for, diabetes in California.
addressing priority areas in diabetes.
Join us in action by taking the
following steps:
Conclusion
An idea without a plan is a dream,
1. Make a commitment and become
a partner with others in your com- but an idea with a plan promotes
munity and with the California action. California’s Plan for Diabetes
Diabetes Prevention and Control is the basis for organizations
Program in addressing diabetes. throughout the state to coordinate
their efforts in diabetes around
“Numbers will give us power to common goals. Diabetes is a huge
and growing problem that cannot
prove that we need to have programs be solved by a single group. The
in specific areas. We need to all Plan should help organizations and
communities identify needs, set
work on collecting data.” priorities, and develop objectives
2. Conduct interventions that best that can be accomplished. The sum
meet the needs of your community. of these coordinated parts will add
Use the Plan to guide intervention up to better results in addressing
choices. diabetes in California.
3. Communicate your work in dia-
betes by sharing your challenges
and successes with the California
Diabetes Prevention and Control
Program and its partners.
18References ADA The Expert Committee on
8
the Diagnosis and Classification of
Diabetes Mellitus: Report of the Expert
1 Okie, S. ‘Pre-diabetes’ tests urged for Committee on the Diagnosis and
overweight Americans. Washington Classification of Diabetes Mellitus.
Post. 3/28/02:A08. Diabetes Care, 26:S103, 2003.
2 Data from the California Diabetes 9 Data from American Diabetes
Prevention and Control Program: Association: Basic diabetes information.
Diabetes Data for California: Prevalence [http://www.diabetes.org/main/
and Risk Factors. California application/commercewf?origin=
Department of Health Services. *.jsp&event=link(B)]
1997. p. iv.
10 Data from Healthy People 2010.
3 Data from the California Diabetes Leading health indicators: overweight
Prevention and Control Program: and obesity.
Overview of Diabetes in California. [http://www.healthypeople.gov/
2002. p.1. document/html/uih/uih_4.htm#over
4 Data from the California Diabetes andobese]
Prevention and Control Program: 11 Data from Centers for Disease
Overview of Diabetes in California. Control, National Center for Health
2002. p.1. Statistics. Prevalence of overweight
5 Data from Centers for Disease among children and adolescents: United
Control: National Center for Health States, 2000.
Statistics. National Vital Statistics [http://www.cdc.gov/nchs/products/
Report, Vol. 50 (16), September 16, pubs/pubd/hestats/overwght99.htm]
2002. p.8. 12 Data from American Diabetes
6 Data from Centers for Disease Association: Children and diabetes.
Control. Diabetes: Disabling, Deadly [http://www.diabetes.org/main/
and on the Rise. 2002. p.2. application/commercewf?origin=*.js
p&event=link(B4_3)]
7 Data from the California Diabetes
Prevention and Control Program:
13 Data from American Diabetes
Overview of Diabetes in California. Association: Pre-diabetes.
2002. p.1. [http://www.diabetes.org/
main/info/pre-diabetes.jsp]
19Glossary California Health Interview
Survey (CHIS): CHIS is the largest
state health survey conducted in
Healthy People 2010: A set of
national health objectives designed
to identify the most significant
Coordinated care delivery model:
the United States. The first survey— preventable threats to health, and
A model of care that integrates
CHIS 2001—collected information to establish national goals to reduce
different components of the health
from 73,821 individuals: 55,428 these threats. The objectives are
care system, such as the providers,
adults, 5,801 adolescents and administered through the U.S.
community, and the patient, into
12,592 parents about a child. CHIS Department of Health and Human
an integrated method of monitoring
collects information on important Services and can be found at
and managing patient care. One of
health conditions such as diabetes, http://www.health.gov/
the most well known examples is
cancer, and asthma. CHIS will bene- healthypeople/default.htm.
the Chronic Care Model developed
fit the health and health care needs
by Ed Wagner and colleagues. Health Plan Employer Data and
of California’s ethnically diverse
Additional information about the Information Set (HEDIS): HEDIS
population since it is enhanced by
Chronic Care Model is available at is a set of standardized performance
cultural adaptation and translation
http://www.improvingchroniccare.org/ measures designed to ensure that
in six languages: English, Spanish,
change/model/components.html. purchasers and consumers have the
Chinese, Vietnamese, Korean and
information they need to reliably
Behavioral Risk Factor Khmer (Cambodian) and includes
compare the performance of managed
Surveillance System (BRFSS): large samples of African Americans,
health care plans. The performance
In California, this state-administered American Indians and Alaska Natives,
measures in HEDIS are related to
telephone survey is part of the Asian Americans and Pacific Islanders
many significant public health issues
surveillance effort conducted by and Latinos. CHIS will survey the
such as diabetes, cancer, heart
the California Department of Health state’s population every two years.
disease, asthma, and smoking.
Services and the Public Health
Gestational Diabetes Mellitus HEDIS also includes a standardized
Institute in cooperation with the
(GDM): GDM is defined as any survey of consumers’ experiences
Centers for Disease Control and
degree of glucose intolerance with that evaluates plan performance
Prevention. The emphasis of this sur-
onset or first recognition during preg- in areas such as customer service,
vey is on health-related behaviors in
nancy. The definition applies whether access to care and claims processing.
the adult population with a specific
insulin or diet-only modification is HEDIS is sponsored, supported
focus on behaviors related to disease
used for treatment, and whether and maintained by the National
and injury. The survey has been
or not the condition persists after Committee for Quality Assurance
ongoing in California since January
pregnancy. It does not exclude the (NCQA).
1984. The annual sample size for
possibility that unrecognized glucose
this survey is approximately 4,000
intolerance may have pre-existed or
interviews.
may have begun during pregnancy.
20Impaired Fasting Glucose (IFG): areas for the
IFG is also known as “pre-diabetes.” national diabetes
IFG occurs when the fasting plasma program:
glucose value is 110-125 mg/dL. (1) establish
These glucose values are greater than measurement
the level considered normal but less procedures to
than the level (126 mg/dL) that is track program
diagnostic of diabetes. success in reach-
ing National
Impaired Glucose Tolerance
Objectives; (2)
(IGT): IGT is also known as
demonstrate suc-
“pre-diabetes.” IGT occurs when the
cess in achieving
blood glucose level is higher than
an increase in
normal, but not high enough to be
the percentage
classified as diabetes. IGT is indicat-
of persons with
ed by a blood glucose level of 140-
diabetes in your
199 mg/dl two hours after drinking
state or jurisdic-
the glucose solution in the oral
tion who receive the recommended (7) demonstrate success in establish-
glucose tolerance test (OGTT).
foot exams; (3) demonstrate success ing useful programs for the promo-
Individual Practice Association in achieving an increase in the per- tion of wellness, physical activity,
(IPA): A network of individual centage of persons with diabetes in weight and blood pressure control,
physicians or physicians in smaller your state or jurisdiction who and smoking cessation for persons
groups. IPAs contract with individual receive the recommended eye with diabetes.
physicians who see HMO members exams; (4) demonstrate success in
Obesity: Obesity is defined as an
as well as patients covered by other achieving an increase in the percent-
excessively high amount of body fat
types of health insurance in their age of persons with diabetes in your
or adipose tissue in relation to lean
own private offices. Physicians in an state or jurisdiction who receive the
body mass. The amount of body fat
IPA are paid on either a capitation or recommended influenza and pneu-
(or adiposity) includes concern for
a modified fee-for-service basis. mococcal vaccines; (5) demonstrate
both the distribution of fat through-
success in achieving an increase
National Diabetes Objectives: In out the body and the size of the
in the percentage of persons with
1999, the Division of Diabetes adipose tissue depots. Individuals
diabetes in your state or jurisdiction
Translation (DDT) at the Centers for with a Body Mass Index (BMI)
who receive the recommended A1C
Disease Control and Prevention, of 30 or more are considered obese.
tests; (6) demonstrate success in
established the following seven http://www.cdc.gov/nccdphp/dnpa/
reducing health disparities for
DDT National Objectives as priority obesity/defining.htm
high risk populations and;
21Overweight: Overweight refers to diabetes within 10 years, but this Secondary Prevention: Testing and
increased body weight in relation to can be minimized through healthy treating people with an established
height, when compared to some eating and physical activity. disease in order to prevent recurrent
standard of acceptable or desirable events or disease progression.
Prevalence: The proportion of per-
weight. Individuals with a BMI of
sons with a particular disease within Type 1 Diabetes: Type 1 diabetes,
25 to 29.9 are considered overweight.
a given population at a given time. previously known as juvenile
http://www.cdc.gov/nccdphp/dnpa/
diabetes, is usually diagnosed in
obesity/defining.htm Primary Prevention: Include
children and young adults. In type 1
efforts that protect individuals
Preferred Provider Organization diabetes, the body does not produce
against disease, and are aimed
(PPO): Some combination of hospi- enough insulin due to autoimmune
at keeping a population healthy.
tals and physicians agree to provide destruction of the insulin producing
health care services to a group of Risk Assessment: A planned pro- beta cells in the pancreas.
people, perhaps under contract with gram to identify those at risk for a
Type 2 Diabetes: Type 2 diabetes
a private insurer. The services may disease by assessing their risk factors.
is a metabolic disorder resulting
be furnished at discounted rates. For diabetes, the American Diabetes
from the body’s inability to make
Patients may incur expenses for Association has a Risk Test (a paper
enough, or properly use, insulin.
covered services they receive outside risk assessment tool) to identify
Type 2 diabetes is the most common
the PPO, if the charge from the high-risk individuals (www.dia-
form of diabetes.
non-PPO provider exceeds the betes.org). Persons identified to be
PPO reimbursement rate. at high-risk should be referred for
diagnostic testing.
Pre-diabetes: Pre-diabetes is the
state that occurs when a person’s Screening/ Diagnostic Testing
blood glucose levels are higher than for Diabetes: Involves checking
normal, but not high enough for a an individual’s blood glucose level
diagnosis of type 2 diabetes. This is in a medical setting to confirm the
also referred to as Impaired Glucose presence or absence of diabetes.
Tolerance or Impaired Fasting If using finger stick testing in a
Glucose, depending upon whether screening program, there must be
an oral glucose tolerance test or a a means of referring individuals
fasting blood glucose test was used. with a positive test for follow-up
People with pre-diabetes have a care. Finger stick testing requires
1 in 3 chance of developing type 2 licensure for laboratory testing.
22Resources California HealthCare
Foundation
www.chcf.org
The following resources may be
useful to organizations seeking Centers for Disease Control
additional information about dia- and Prevention
betes. Some of the resources also www.cdc.gov/health/diabetes.htm
provide funding to selected agencies.
Health Disparities Collaborative
Please contact the organization
www.healthdisparities.net
directly for additional information.
Improving Chronic Illness
American Diabetes Association
Care Program
www.diabetes.org
www.improvingchroniccare.org
California Diabetes
Integrated Health Care
and Pregnancy Program
Association
www.dhs.mch.ca.gov/programs.htm
www.iha.org
www.llu.edu/llumc/sweetsuccess
Juvenile Diabetes Research
Foundation
“The landscape of diabetes is changing www.jdrf.org
for the better. But we’ve got a long way National Committee
for Quality Assurance
to go and we must keep working at it.
www.ncqa.org
Every person is important.”
National Diabetes Education
Program
www.ndep.nih.gov
California Diabetes Prevention
and Control Program Robert Wood Johnson
www.caldiabetes.org Foundation
www.rwjf.org
The California Endowment
www.calendow.org
23Acknowledgements
Individuals from the following organizations contributed significant time and energy to the development
of California’s Plan for Diabetes. Their feedback and support is great appreciated.
Alameda County Health Care Services Agency
American Diabetes Association
Association of Asian Pacific Community Health Organizations
California Diabetes Prevention and Control Program
CMRI - The California Quality Improvement Organization
California Primary Care Association
Community Health Councils, Inc. REACH 2010
Diabetes Coalition of California
Health Net
Lifescan, Inc.
Project Dulce
Special thanks to:
Hull + Honeycutt Marketing and Design, Inc.,
who donated graphic design and layout services and the
Diabetes Coalition of California,
who funded the printing of the Plan.
NAS Consulting and Samuels and Associates provided technical assistance for this project.
Photography © Susie Fitzhugh, Seattle, Washington.
We want to hear from you!
Tell us what you think of California’s Plan for Diabetes.
Check out our web-based reporting tool. Download valuable
diabetes resources. Join our online mailing list.
www.caldiabetes.org
24To gather additional input for the Hill Physicians Medical Group, Inc. San Diego State University
Plan, ten community meetings were Homeys Youth Foundation - California San Francisco Department
held throughout California and a Home Instruction Program for Preschool of Public Health
draft was posted on the California Youngsters
Diabetes Prevention and Control San Mateo Community Health Services
Program’s web site. Common Juvenile Diabetes Research Foundation Sharp Health Care
themes were included in the Plan Kaiser Permanente, Los Angeles
from the following organizations: Sonoma Valley Community
Kaiser Permanente, Northern California Health Clinic
Alameda Alliance for Health
Latino Community Diabetes Council Southwest Community Health Center
Alameda County Public Health
Department Los Angeles County Area Agency Stanford Patient Education
on Aging Research Center
American Association of Retired Persons
(AARP) Los Angeles County Department Stanford University
of Health Services St. Mary’s Medical Center
Asian Pacific Health Care Venture
Los Angeles County DHS Children’s St. Johns Health Center
Aventis Pharmaceuticals
Health Initiatives
Blue Cross of California State St. Vincent Medical Center
Los Angeles County Office of Education
Sponsored Programs St. Vincent Medical Center
Los Angeles Metropolitan Medical Educational Services
Brookside Community Health Center
Center
Bristol Myers & Squibb Summit Health Ministry
Los Angeles County + University
California Black Health Network of Southern California Health Care Sutter Health Family Practice Center
California Diabetes in Pregnancy Network (LAC+USC Health Care Therasense
Program Network)
The Children’s Clinic
California Heart Disease and Stroke Queen of Angels Hollywood
Presbyterian Medical Center— The Salvation Army
Prevention Program, Department
of Health Services Tenet Health System University of Southern California (USC)
National Asian Women’s Health Advanced Biotelecommunications and
California Hospital Medical Center Bioinformatics Center (ABBC)
Organization (NAWHO)
California Medical Association University of Southern California School
Mini Pharmacy
Charles R. Drew University of Science of Policy, Planning, and Development
and Medicine/University of California, Multicultural Area Health
Education Center U.S. Food and Drug Administration,
Los Angeles Los Angeles District
Children’s Hospital Oakland Northern California Center
for Wellbeing Ventura County Medical Research
Community Health Partnership Foundation
Oakland Unified School District
County of San Diego Ventura County Chronic Disease
Pajaro Valley Community Health Trust Prevention Partnership
Diabetes Amputation Prevention
Foundation Por La Vida Ventura County Public Health
Diabetes Society of Sonoma County Project Concern International California’s Plan for Diabetes is
Redwood Community Health Coalition evolving as we continue our work
Disetronic Medical Systems, Inc.
in diabetes. We invite you to partici-
Doheny Retina Institute Sansum Medical Research Institute pate in the implementation of the
Fullerton College Student/PUENTE Santa Clara County Chapter of Plan and join the list of supporting
American Association of Diabetes organizations.
Gardner Family Health Network Educators (AADE) The Plan is available for download
Health Promotion and Binational/Border Santa Clara County IPA at www.caldiabetes.org. Continue
Health, Health Education Program to check the web site as updates to
Santa Clara Valley Medical Center
Health Trust the Plan are posted.
Diabetes CenterYou can also read
