Improving Outcomes for Diabetes in African Americans: Lessons Learned for REACH Charleston and Georgetown Diabetes CoalitionCarolyn Jenkins, DrPH, APRN-BC, RD, FAANAnn Darlington Edwards Chair and ProfessorMedical University of South Carolinaphone: 843-792-4625e-mail: jenkinsc@musc.edu

Goals for TodayReview diabetes statistics.Share some processes and outcomes from community-based participatory research and service learning.Review an expanded chronic care model for improving outcomes in African American communities.Explore needed community changes.

Diabetes is the Fifth Deadliest Disease in the U.S. and Its Prevalence is IncreasingU.S. Prevalence(% of population)19994.9% 6.9%Lifetime Risk if Born in 200033%39%Whites:African Americans:40%50%27%31%Hispanics:45%53%Sources: American Diabetes Association: Economic Costs of Diabetes in the U.S. in 2002. Diabetes Care. 2003;26:917-932.Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk of diabetes mellitus in the United States. JAMA. 2003;290:1884-1890.American Diabetes Association: Diabetes Statistics for African Americans. Available at: www.diabetes.org/diabetes-statistics/african-americans.jsp. Accessed March 14, 2005.American Diabetes Association: Diabetes Statistics for Latinos. Available at: www.diabetes.org/diabetes-statistics/latinos.jsp. Accessed March 14, 2005. 20057 to 9.6%

How Serious Is Diabetes?Source: Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk of diabetes mellitus in the United States. JAMA. 2003;290:1884-1890. It predictably affects both lifespan and quality of life4040Age at diagnosis:Lost # of life years:18- 2021 - 2411 - 1312 - 17Lost # of quality-adjusted life years:

The Burden of Diabetes Is Greater for Minority Populations in the United States2.7 million (11.4%) over age 20 60% higher than in whitesHigher complication rates2X as likely to suffer lower-limb amputations2X as likely to suffer from diabetes-related blindnessDiabetes in African AmericansDiabetes affects:Sources: American Diabetes Association: Diabetes Statistics for African Americans. Available at: www.diabetes.org/diabetes-statistics/african-americans.jsp. Accessed March 14, 2005.

American Diabetes Association: Diabetes Statistics for Latinos. Available at: www.diabetes.org/diabetes-statistics/latinos.jsp. Accessed March 14, 2005.

Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23:1278-1283. 10.8% of African Americans10.6% of Hispanics6.2% of Whites

The Financial Impact of Diabetes Is StaggeringTotal Health Care Costs in 2007Per capital costs averaged $11,744Indirect Expenditures: $58BDiabetes: $132BLost workdaysRestricted activity daysMortalityPermanent disabilityDiabetes Care$27BRelated Complications$58BOther Medical Care$31BDirect Expenditures: $92BSource: American Diabetes Association: Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. 2008;31,1-20.

Diabetes CostsAnnual health care costs for people with diabetes: $11,744.One of every 5 health care $ spent caring for person with diabetes.One of every 10 health care $ is attributed to diabetes.Costs for people with diabetes 2.3 X higher than those without diabetes.Diabetes Care 2008

South Carolina StatisticsIn 2005 BRFSS:10.3% reported they had diabetesAfrican Americans (15.4%)Non-Hispanic Whites (8.4%)Insulin treated (29.5%)Pills (72.9%)A1C test in past year (77%)Never had A1c (23%)Diabetic eye disease (21.7%)No insurance and/or no doctor (~18%)African Americans (26.6%)Non-Hispanic whites (15.1%)

Risk Factors Among African Americans in SCCurrent Overweight Sedentary HBP Diabetes High Smoker Obesity Lifestyle CholesterolDiabetes in SC:Two-thirds of people with diabetes die of heart disease and stroke1 of every 7 African-Americans has diabetes, which is 80% higher than rate for non-Hispanic whites.

Diabetes in African Americans in South CarolinaIn Charleston and Georgetown Counties, 21% of African Americans reported having diabetes (2005 RRFS)

Rural African Americans with diabetes:60.6 % have inadequate control versus 42.5% of urban whites (SC BRFSS)

Disease risk, diagnosis, progression of disease, response to treatment, caregiving, and overall quality of life are all affected by a number of variables including race, ethnicity, gender, socioeconomic status, age, education, occupation, country of origin, and perhaps other lifetime and lifestyle differences.

DIABETES-ATLAS Conceptual Model National Minority Health Month Foundation (2007)http://www.nmhmf.org/diabetes_initiative.aspx

Percentage of the 2005 PopulationDiagnosed with diabetes

1994-present

CBPAR Activities and Diabetes Management

From Meredith Minkler, DrPH University of California, Berkeley

Enterprise Neighborhood Health Program (1994 1998)HUD Grant with Charlestons Enterprise Community to a) recruit and train community leaders to become Community Health Advocates;b) conduct needs assessment.

Needs assessment identified diabetes and HTN as priority issues.

61 community health advisors trained.

Video documenting needs and assets using community voices

AKA Summer Enrichment Program for children

Diabetes Initiative of South Carolina1994Report to SC Legislature on Scope and Problems of Diabetes in SC

Funding by State Legislature to create Center to address diabetes in SCCenter of Excellence at MUSCProfessional CouncilOutreach CouncilSurveillance Council

Annual Report on activities and outcomes to South Carolina Legislature and Governor

Enterprise Health Center 1995 - 2001Donation of LotBuilding CompletedOpened November 2001Now a FQHC site (FCFFHC)

Service-LearningAn educational methodology based on a community-campus partnership which combines student community service with explicit learning objectives. Students participating in service-learning are not only expected to provided direct community service but also to learn about the context in which the service is provided, and to understand the connection between the service and their academic coursework.Seifer 1998

Service Learning with Students>700 students (MUSC, Clemson, Howard, USC, Rhode Island, UNC)7 Doctoral Candidates/Graduates6 Certified Diabetes Educators

7 doctoral dissertations3 masters thesis20 regional or national presentations10 peer-reviewed publications

Healthy South Carolina Hypertension and Diabetes Management and Education Program (HAD-ME)Health care team conducted weekly screening, management, and education clinics (with linkages to primary care) in inner-city neighborhoods (1997-2001)

> 900 community residents with diabetes and/or hypertension participated.

> 1,100 referrals to primary care

Significant decreases in BP, blood glucose, and weight

REACH 2010: Charleston And Georgetown Diabetes Coalitions Efforts to Decrease Disparities for Diabetes Arlene Case-The Lesson

A heath disparity population is a population where there is significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population1.

Minority Health and Health Disparities Research and Education Act of 2000

REACH 2010: Charleston and Georgetown Diabetes CoalitionTennessee South Carolina SC DHECRegion 6GeorgetownDiabetesCORE GroupSt. James Santee HealthCenterEnterprise HealthCenterEnterprise CommunityTri County BlackNursesMUSCMUHADiabetes InitiativeCollege of NursingAlpha KappaAlpha SororityFranklin C. FetterFamilyHealth CenterTrident United WayGeorgetownNorth CarolinaGeorgiaCharlestonCounty LibraryStatewide REACH home-basedin Columbia:Communicare SC DHEC SC DPCPCarolina Center for Medical ExcellenceTriCounty FamilyMinisteriesSC DHECRegion 7County Library East Cooper Community Outreach

S. SanteeSt. JamesSenior Center

Methods and InterventionsCommunity skill-building and neighborhood clinics175 lay educators trainedDiabetes self management educationFoot care trainingWise Woman for AA women 40-70 years old

Community health professional training145 RNs with advanced foot/wound education27 physicians with foot care education

Outreach by professional and lay educators 30 minute TV program aired 34 times on cableLibrary program/Internet useWeekly diabetes management classes in 8 sites

Health systems changeRegistry and reminder systemCQI teamsCoalition building and policy change

Skill-Building forCHAs and VolunteersNeighborhood Walk and TalkGroupsIndividual and Group Education SessionsCommunity and Media Activities reached >40,000 African AmericansCommunity Screening and Education

Percent with > Annual A1c by Race (increased from 76.8% in 1999 to 97.1% in 2006)

Percent with > Annual Lipid Profile by Race (increased from 47.3% in 1999 to 87.2% in 2006)

Percent with Kidney Testing (microalbuminuria) by Race(increase from 13.4% in 1999 to 56% in 2006)

Percent with > Annual Foot Exam by Race (increased from 64.1% in 1999 to 97.3% in 2006)

Percent with BP < 130/80 by Race (increased from 24% in 1999 to 38.2% in 2006)

Percent of Visits with Teaching by Race (increased from 41% in 1999 to 93% in 2006)

Lower Extremity Amputations (1999-2002) Charleston County

www.musc.edu/reach

Although studies documenting disparities are not in short supply, findings about what works to reduce disparities are. A 3-year, $6-million program called Finding Answers: Disparities Research for Change, sponsored by the Robert Wood Johnson Foundation, seeks to identify effective interventions to eliminate disparities.

Under the direction of Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago Pritzker School of Medicine, the program reviewed more than 200 journal articles on disparity reduction interventions in cardiovascular disease, depression, diabetes, and breast cancer. The results appeared in October 2007 in a supplement to Medical Care Research and Review.

One of the few studies in the review that showed a reduction in racial disparities was part of the Racial and Ethnic Approaches to Community Health (REACH 2010) program, sponsored by the US Centers for Disease Control and Prevention in Atlanta, Ga. The demonstration program, which took place in Charleston and Georgetown counties in South Carolina, brought together 28 community partners, from health professionals to college sororities and local media, that set goals to improve diabetes care for blacks as well as eliminate health care disparities between black and white patients with diabetes.

The partners documented disparities in care for 12,000 black patients with diabetes in the 2-county community. The intervention included such community activities as health fairs, support groups, grocery store tours, community clinics, and church-based educational programs. After 24 months, the partners audited medical charts for 158 black patients and 112 patients who were white or of other racial or ethnic groups. They found that differences between black and white patients in rates of hemoglobin A1c testing, lipid and kidney testing, eye examinations, and blood pressure control that had ranged from 11% to 28% at baseline had been eliminated (Jenkins C et al. Public Health Rep. 2004;119[3]:322-330).

Chin is optimistic that other communities will develop their own, similar programs in the future. "There are a lot of promising models," he says. "But you may have to revise as you go along, just like in patient care."

Quote from R. Voelker in JAMA 2008;299(12):1411-1413.

REACH US:SouthEastern African American Center of Excellence for Eliminating Disparities for Diabetes

REACH US SEA-CEED

REACH US Center of ExcellenceA coordinated multi-system, multi-media, intergenerational approach to prevention and control of diabetes and its cardiovascular complications to eliminate health disparities in African Americans at risk and with diabetes.

Geographical Areas: African Americans with Diabetes and Stroke in North Carolina, South CarolinaGeorgia

What is needed to improve diabetes care and outcomes in African Americans in South Carolina?

IOMs 8 Competency AreasInformaticsGenomicsCultural competenceCommunicationsCommunity based participatory researchEthicsPolicy and lawGlobal healthGebbie et al. (2001)

Evidence-Based PracticePractice supported by research findings and/or demonstrated as being effective through a critical examination and review of current and past practices. EBP integrates patient preferences with research evidence, to determine best course of action to improve health.

*Listen to the Stories

While the stories are being told, dont offer solutions too early!! Work together to identify the issues and develop the solutions.

*Go to the people.Live among the people.Learn from the people.Work with the people.Start with what the people know.Build on what the people have.Teach by showing, learn by doing.Not a showcase but a pattern.Not odds and ends, but a system.Not piece meal, but an integrated approach.

Social & Economic PoliciesInstitutionsNeighborhoods/CommunitiesLiving ConditionsSocial RelationshipsIndividual Risk FactorsGenetic/Constitutional FactorsPathophysiologic PathwaysIndividual and Population HealthLife CourseEnvironmentDeterminants of Health from National Academy of Sciences, Epidemiology Review 2004;26:124-125

Informed,ActivatedPatientProductiveInteractionsPrepared,ProactivePractice TeamImproved OutcomesDelivery SystemDesignDecisionSupport Clinical Information SystemsSelf- Management SupportHealth SystemResources and PoliciesCommunity Health Care OrganizationChronic Care ModelWagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice(1), 2-4.

A Model for Chronic Illness CareDelivery SystemDesign DecisionSupport

Clinical Information Systems

Self-Management Support

Health System Organization

Links to Community ResourcesAdapted from: Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice(1), 2-4.

World Health Organization Social Ecology Adaptation of Wagners Chronic Care ModelNotice the added community involvementStill low on patient, family & social network participation or accounting for sociocultural variations

Taken from Epping-Jordan, J., Pruitt, S., Bengoa, R., and Wagner, E. (2004). Improving the quality of health care for chronic conditions. Quality and Safety in Health Care, 13, 200-305. doi:10.1136/qshc.2004.010744

Conceptual Model for REACH US: Charleston and Georgetown Diabetes Coalition (adapted from Jenkins et al., Barr et al. , Wagner)1 Environment is viewed through an ecological framework and includes social, political, and economical aspects.2 To categorize the various community resource systems, we use the Community Systems Wheel (Anderson and McFarland, 2006). The systems include: Health and Social Services, Politics and Government, Safety & Transportation, Education, Communication, Economics, Recreation, and Physical Environment. We added Faith-based Services.

Community-Based Participatory Action ResearchA collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community, has the aim of combining knowledge with action and achieving social change.

WK Kellogg Foundation Community Health Scholars Program

Fundamental Characteristics of CBPARIt is:participatory.cooperative, engaging community members and researcher(s) in a joint process with both contributing equally.a co-learning process.an empowerment process through which participants can increase control over their lives.

*Fundamental Characteristics of CBPARIt involves systems development and local community capacity building.

It achieves a balance between research and action. (Israel et al. 1998)

It involves sharing of funding among partners (usually equally).

Understanding culturesCommunity cultureAcademic and institutional cultureDiffering philosophies.Sharing of budgets in an equitable way.Clearly defining and continuously implementing our principles for the partnership in a fair and equitable way.Identified Challenges for Communities and Academic Institutions

Instructions for Community for Partnering with Academic Institutions--Look For People that:

Begin their discussions with you by asking questions, rather than offering solutions.Recognize the gap between measuring differences and making differences.Demonstrate a willingness to help you measure the differences you make.Share control over financial resources and decisions with community representatives.Express commitment to a working relationship built on trust and equity.

Prev Chronic Dis. 2004 January; 1(1): A12.

Common Characteristics of Successful Community-Institutional PartnershipsTrusting relationshipsEquitable processes and proceduresDiverse membershipTangible benefits to all partnersBalance between partnership process, activities, and outcomesSignificant community involvement in scientifically sound research (Continued on next slide)Seifer, 2006

Common Characteristics of Successful Community-Institutional PartnershipsSupportive organizational policies/reward structureLeadership at multiple levelsCulturally competent and appropriately skilled staff and researchersCollaborative disseminationOngoing partnership assessment, improvement and celebrationSustainable impactSeifer, 2006

Recommendations for Emerging and Established PartnershipsPay close attention to membership issuesBuild on prior history of positive working relationshipsObtain support and involvement of both top leadership and front line staff of partner organizationsEmbrace diversity in the partnershipDecide who the community is and who represents the community.Seifer, 2006

Recommendations for Emerging and Established Partnerships (continued)Develop rationale, criteria and procedures for adding new partnersDevelop structures and processes that facilitate the development of trust and sharing of influence and control among partnersJointly develop partnership principles and operating proceduresJointly create mission, vision, and priorities for the partnershipSeifer, 2006

Recommendations for Emerging and Established Partnerships (continued)Strive to achieve an equitable distribution of costs, benefits, and resources among the partnersConduct ongoing evaluation of partnership processBuild the capacity of all partners Plan ahead for sustainabilityPay close attention to the balance of activities within the partnershipBe strategic about disseminationSeifer, 2006

Build Capacity of All PartnersFacilitate partner training, technical assistance and continuing educationInvest partnership resources in local communityEstablish and maintain partnership infrastructure

Seifer, 2006

*Cultural Humility: A life long commitment to self evaluation and self critique to redress power imbalances and develop and maintain respectful and dynamic partnerships with communities Tervalon & Garcia, 1998

*Assets in CommunityFrom: Kretzmann & McKnight. (1993) Building Communities from the Inside Out

*Identifying Natural Community LeadersWhen you have a problem, who do you go to for advice?Who do others go to?When people in the neighborhood have come together around a problem in the past, did a particular individual or group play a key role?What things do people tell you youre good at?Eng et al, 1990; Israel, 1985; Sharpe, 2000

Insider-Outsider TensionsPower dynamics; the power of authority of the outsiders often multiple sources of unspoken privilege (Wallerstein, 1999)Conflicting time tables & demandsDifferential reward structures (Minkler, 2006)

Perceived clash between community desires and good science

*We want to know how much you care, before we know how much you know. Alma Joseph Flores Enterprise Community

PartnershipA strategic combining of resources that create power far beyond the capabilities of individual players working alone.

Thanks to Our Team (and to you)!REACH Community Partners and StaffGayenell Magwood, Barbara Carlson, Jane Zapka, Martina Mueller, Leonard Egede, Marilyn Laken, Montrese Edwards, Virginia Thomas, Joyce Linnen, Lee Moultrie, Sonja Smalls, Syndia Moultrie, Karen Hill, George BushREACH Partners Coaltion

Charleston Diabetes Coalition

Georgetown Diabetes CORE Group

Diabetes Initiative of South CarolinaDr.John Colwell Dr. Kathie HermayerDr. Dan LacklandDr. Brent EganPamela Arnold

SC Diabetes Prevention and Control Program

Centers for Disease Control and PreventionNational Institutes of Health-NIDDKAmerican Diabetes Association

*Thank you.

It is an honor to share our work in decreasing disparities and health care costs for African Americans with diabetes.Since 1977 I have worked with African American communities and engaged students in community-based service learning to improve health outcomes. Since completing my doctoral coursework in Public Health in 1994, Ive focused my research activities on community-based participatory research or CBPR.

CBPR is defined by AHRQ as:a collaborative process of research involving researchers and community representatives; it engages community members, employs local knowledge in the understanding of health problems and the design of interventions, and invests community members in the processes and products of research. In addition, community members are invested in the dissemination and use of research findings and ultimately in the reduction of health disparities. *(Title Appears) Diabetes is now the fifth deadliest disease in the United States, and its prevalence is continuing to increase.1 (Top 2 Blue Text Boxes Appear) Between 1990 and 1999, (1st LH Text Box Appears) the disease grew by more than 40 percent, affecting (1st LH Percentage Appears) 4.9 percent of the population in the beginning of the decade and (Arrow & 1st RH Percentage Appears) 6.9 percent by the end. And future projections offer little encouragement. (2nd LH Text Box & Bottom 2 Blue Text Boxes Appear) For those born in the year 2000, roughly (2nd LH Percentage Appears) 1 in 3 males and (2nd RH Percentage Appears) 2 in 5 females will suffer from diabetes in their lifetime. (White Percentages Appear) For minority groups, the outlook is particularly grim. Trends show that (African American Percentages Appear) African Americans and (Hispanic Percentages Appear) Hispanics will continue to be disproportionately affected if the diabetes epidemic is not addressed head-on.2,3,4 *(Title Appears) How serious is diabetes? Lets put it in these terms: (Top Text Box & Picture Appears) diabetes is somewhat predictable when it comes to its effect on both lifespan and quality of life. (LH Blue Text Box Appears) If you are a male, (1st LH Text Appears) diagnosed with diabetes at (40 Appears) age 40, your life, on average, (2nd LH Text Appears) will be shortened by (11-13 Appears) 11 to 13 years. When you consider both numbers of years and quality of life during those years, the impact is greater. (3rd LH Text Appears) Males with diabetes lose (12-17 Appears) 12 to 17 quality-adjusted life years. (RH Blue Text Box & 40 Appears) Females fare worse, losing (18-20 Appears) 18 to 20 years of life and (21-24 Appears) 21 to 24 quality-adjusted life years.2*(Title Appears) As I mentioned, the burden of diabetes is greater for minority populations than the white population in the United States. (1st Part of Top Text Appears) Diabetes affects (2nd Part of Top Text Appears) 10.8 percent of African Americans and (3rd Part of Top Text Appears) 10.6 percent of Hispanics, compared with (4th Part of Top Text Appears) 6.2 percent of whites.5 (LH Blue Text Box & 1st LH Bullet Appear) Approximately 2.7 million, or 11.4 percent, of African Americans aged 20 years or older have diabetes a rate that is (Sub-Bullet Appears) 60 percent higher than in whites. Thus, they experience (2nd LH Bullet Appears) higher rates of at least four serious complications of diabetes: cardiovascular disease, blindness, amputation, and kidney failure. For example, among people with diabetes, African Americans are (1st Sub-Bullet Appears) twice as likely to suffer from lower-limb amputations and (2nd Sub-Bullet Appears) twice as likely to suffer from diabetes-related blindness.3(RH Blue Text Box Appears) Hispanics are in a similar situation. (1st RH Bullet Appears) Two million, or 8.2 percent, of Hispanics aged 20 or older, are affected by diabetes -- a rate that is (Sub-Bullet Appears) 50 percent higher than in whites. (2nd RH Bullet Appears) As for complication rates, (1st Sub-Bullet Appears) 35 percent of Mexican Americans are plagued by eye complications, and, among people with diabetes, Mexican Americans are (2nd Sub-Bullet Appears) 5 times more likely to suffer from kidney failure.4

*(Title Appears) The financial impact of diabetes on our nation is also staggering. (Top Bold Text Line Appears) With a total cost of health care of $865 billion in 2002, (Top Blue Text Box Appears) diabetes accounted for about $132 billion of that. (LH Lines & LH Blue Text Box Appears) Direct medical expenditures totaled $92 billion, (LH Lines & LH Text & Outline Appear) including $23 billion for diabetes care, (Middle Lines & Middle Text & Outline Appear) $25 billion for chronic diabetes-related complications, (RH Lines & RH Text & Outline Appear) and $44 billion for excess prevalence of general medical conditions. (RH Lines & RH Blue Text Box Appears) More than $40 billion worth of indirect costs were attributable to (1st Bullet Appears) lost workdays, (2nd Bullet Appears) restricted activity days, (3rd Bullet Appears) mortality, and (4th Bullet Appears) permanent disability due to diabetes. 1For the next few minutes, I will share a few of our CBPAR activities and outcomes. This work helped to establish the newly approved Center for Community Health Partnerships as a university center.Often, our students and our community members see the real work and academia as two different paths or roads. My goal has been to unite the two through CBPR.Our CBPR activities began with the Enterprise Neighborhood Health Program and a comprehensive needs assessment where community residents identified diabetes and hypertension as priorities that they wanted to address. They wanted to learn more about how to better manage these health problems. Community residents volunteered to attend trainings and work on health activities in their communities.Additionally, community residents, working with cities of Charleston and North Charleston, and MUSC, built a health center in North Charleston focused on improving disparities. The Enterprise Health Center is now a partner of Franklin C. Fetter and is a Federally Qualified Health Center site.Since 1999, more than 750 students have participated in semester long activities, while completing 10 Masters or doctoral research thesis or dissertations, and multiple presentations and publications.MUSCs Healthy South Carolina Initiative funded another CBPAR project. An interdisciplinary health team conducted weekly walk-in screening and education activities in 5 community sites. Many participants did not have a medical home and traditionally used the ER at an average cost of more than $1,200 per visit and many were uninsured. More than 900 residents with diabetes and /or hypertension participated and more than 1,100 referrals to primary care were made. Participants with more than 4 visits had significant decreases in BP, glucose, and weight. *The HADME program provided the preliminary data for obtaining CDC finding for our REACH Program to decrease disparities for African Americans with diabetes.Multiple partners worked together to identify differences or disparities in diabetes self-management, health care, and outcomes.*REACH activities were focused on:**Community skill-building**Health professionals training and education, and health systems change**Coalition building and policy change.*Our activities reached more than 40,000 African Americans.*And health outcomes improved. In this program, amputations for AA men have decreased significantly by almost 50% in 3 years and based on 2006 data, we have maintained that reduction. With the cost of a single amputation at about $37,000, the cost saving is >$2 million. Although the $ savings is significant, more importantly is the human suffering prevented and the improved quality of life.*For example, today Ms. Dilligard is 76 years old. She was a patient in a community hospital and her leg was to be amputated. A family member attended one of the foot care classes offered by a REACH community health advisor, and requested a second opinion from an MUSC physician, who saved her leg. She says, Ill show my leg to anybody. She has scars, but she has her leg. She walks without assistance, and has a quality of life she almost lost She got a referralshe got hopeshe got quality care. Health information and advocacy, along with quality care, work well together.*You can see Ms. Dilligards story on our website. We are making progress and we will continue to integrate research into ongoing activities to decrease diabetes disparities. For additional information about REACH 2010, visit our website.

Our program received two national awards and several state and local awards including:The Community Campus Partnership for Health Award and the Health Information Award for Libraries from the National Commission on Libraries and Information Science for best health outreach program in 2006.In the March 26, 2008 issues of JAMA, our REACH program was listed as one of the few studies in a review of more than 200 journal articles on disparity reduction interventions that showed a reduction in racial disparities. Dr. Marshall Chin from the University of Chicago stated that he is optimistic that other communities will develop their own similar programs in the future.Last Fall, the REACH US Center of Excellence was funded by CDC for 5 years. It is a coordinated multi-system, multi-media, intergenerational approach to prevention and control of diabetes and its cardiovascular complications in African Americans at risk and with diabetes. This project will focus on both diabetes prevention and diabetes control.About 50% of funding will continue many of the REACH 2010 activities in Charleston and Georgetown Counties. Additionally, we will work with 2-3 counties in the Stroke Belt of Georgia, SC, and NC that have an African American population of >30%. Our efforts will be directed towards decreasing health care disparities related to diabetes and its complications emphasizing glucose and hypertension control, and reductions in amputations and strokes.Many community partners will work with the program and we will work towards community and systems change, as well as health systems change. However, only about 2% of diabetes care is provided by the health system. Most of the changes that affect health of people at risk and with diabetes, need to occur within family and community systems. Thus, our focus is on translating Wagners chronic care model for health systems into other community systems.Additionally, the Institute of Medicine in 2001 recognized CBPR as one of the 8 new competency areas for health care.*All along we had heard listen, but often because of our own issues and systems issues, we dont always listen to the stories and work together to identify a plan of action. We must listen carefully if we want to bring about health improvements in individuals, families **One of the issues that we experience is that other researchers want to recruit our volunteers and community education participants for their studies.

Thus, these questions were formulated to assist the community leaders in evaluating the researcher and their research.*More recently, we have recognized the power of partnerships to bring about health improvements in communities.*In closing, I want to recognize the team that has made this research possible and a special thank you to Dr. Gail Stuart, the Dean of the College of Nursing who has continuously supported our efforts, Dr. John Colwell, my mentor who has recently retired, and Dr. Sabra Slaughter who has offered his continuous support and guidance. Thank you for the opportunity to share our efforts.