Updated: April 2021
Accomplishments
Aim 1: Reduce complications and improve quality of life of people living with diabetes.
Year 1
- Established contracts and working partnerships with Eskenazi Health, Local Initiatives Support Corporation, Marion County Public Health Department, Polis Center, and Regenstrief Institute
- Collaboratively designed community health workers (CHW) intervention with Eskenazi Health
- CHW assessments and workflow collaboratively designed and integrated into the Eskenazi Medical Record System
- Developed data collection system for neighborhood CHWs
Year 2
- Three full-time community health workers (CHWs) were directly funded by the project with Eskenazi Health providing funding for an additional three CHWs, bringing the total to six CHWs actively working on DIP-IN through Eskenazi Health
- CHWs began recruiting patients Year 2 Quarter 1 in a graduated approach
- Eskenazi CHWs serve DIP-IN residents at five FQHCs
- Enrolled 257 patients by end of year
- 105 patients referred for social needs
- 165 patients referred internally for medical needs
- Eskenazi identifies diabetes as a key issue as part of their HRSA accreditation due in part to the work of the CHWs
Year 3
- Eskenazi CHWs serve DIP-IN residents at five FQHCs
- CHWs have enrolled an additional 120 patients despite COVID-19 and being unable to do home visits (a critical aspect of the intervention)
- 377 patients total enrolled (64 percent contacted agreed to participate) (as of 1/14/21)
- CHWs have completed over 3,700 appointments (data as of 1/14/2021)
- CHWs serving as a resource
- Have taken on additional responsibilities during COVID-19
- Served as “Way finders,” helping to direct patients at a COVID-19 testing site
- Continue to help deliver pulse oximeters to patients who are discharged on oxygen for home monitoring
- Continue to help deliver food boxes to food-insecure patients who test positive for COVID-19
- Have taken on additional responsibilities during COVID-19
- CHWs assisting INCHWA and IN Dept of Health to develop a diabetes training module
- Continue working with the steering committees
Aim 2: Increase awareness of risk factors for diabetes and encourage people at high risk to be screened so they can take action.
Year 1
- Established partnership with LISC to serve as liaison with community organizations
- Collaboratively designed the RFP process to ensure that DIP-IN steering committees were the decision makers in selecting the CBOs to house the neighborhood CHWs
- Conducted an RFP process to solicit interest from neighborhood organizations
- Selected CBOs to house neighborhood CHWs
Year 2
- Trained CBOs on supervising CHWS
- Hired 3 neighborhood CHWs
- Conducted 41 neighborhood outreach events, reached 911 residents
- Hosted or attended 41 community outreach events representing DIP-IN and reached an estimated 911 people at these events
- Completed 55 diabetes screenings using the American Diabetes Association (ADA) risk tool.
- Attended 87 meetings with 67 unique organizations for purposes of building the network of community resources and supports.
Aim 3: Fostering an environment (physical and social) that supports greater health and wellbeing for all residents (primary prevention)
Year 1
- Established steering committees in each DIP-IN community
- Conducted key informant interviews with key stakeholders identified by steering committee members
- Collaborated with steering committees on design and implementation of community surveys
Year 2
- Steering committee members raised awareness about the survey by discussing at neighborhood meetings and asking local businesses to place posters
- Steering committees used data from the community surveys to inform their primary prevention topics selections:
- Near West—Life stressors
- Northeast—Food access and healthy eating
- Near Northwest—Physical activity access and barriers
Year 3
- Steering committees are worked through coordinating existing resources and identifying evidence-based sustainable strategies to take a coordinated approach to selected focus areas.
- Example: Multiple entities in Northeast community are already working or have vested interest in food access. Steering committee working to see how it can collaborate to make the effort stronger, including potentially partnering to establish a coalition around food access.
- Communities began implementing primary prevention activities including:
- Funding activity classes
- Developing a promotional campaign
- Funding community gardens
- Sponsoring health fairs
- Providing matching funds for a community trail