COMMUNITY HEALTH COMMUNITY HEALTH ENGAGEMENT PROGRAM ENGAGEMENT PROGRAM (CHEP)(CHEP)

DIRECTORS: DIRECTORS:

RONALD T. ACKERMANN, MD, MPHRONALD T. ACKERMANN, MD, MPHDAVID G. MARRERO, PHDDAVID G. MARRERO, PHD

AimsAims

1.1. Engage the Community in Engage the Community in ResearchResearch

A.A. Community residentsCommunity residents

B.B. Community organizationsCommunity organizations

C.C. Community healthcare providersCommunity healthcare providers

2.2. Foster Communication Among CTSI Foster Communication Among CTSI StakeholdersStakeholders

A.A. ScientistsScientists

B.B. Healthcare providersHealthcare providers

C.C. Broad communityBroad community

CHEPCHEP

Community Health Engagement Program Administrative oversight and management of community

engagement, practice & community data integration, communications, technical assistance, training in community

CHEP Executive Committee

CHEP Project Coordination Teams

Community Advisory

Board Professional

Societies

Faith-based Orgs

Community Provider Groups

Indiana Minority Health

Coalition

Community Organizations

(4H, YMCA)

Parks & Recreation

Depts

Health Dept.

Offices

Purdue

Extension Partners

Mayor’s Action Council

Community Population Engagement

Advancing Community Research Methods

Purdue Extension

Community Provider Engagement

Communication Action Team

Network Coordinator

Public Schools Systems

Engaging Non-healthcare Engaging Non-healthcare Community - GoalsCommunity - Goals

Learn and communicate CTSI needs and Learn and communicate CTSI needs and resourcesresources

Seek active community participationSeek active community participation Match community priorities with CTSI Match community priorities with CTSI

funding opportunitiesfunding opportunities Collaborate about strategies for engaging all Collaborate about strategies for engaging all

population groups in researchpopulation groups in research

Engaging Non-Healthcare Engaging Non-Healthcare Community - WhoCommunity - Who

Community Advisory GroupCommunity Advisory Group– Community Executive BoardCommunity Executive Board– Community Advisory CounselCommunity Advisory Counsel

Purdue ExtensionPurdue Extension Department of Communication – IUPUIDepartment of Communication – IUPUI

Engaging Healthcare Engaging Healthcare Community - GoalsCommunity - Goals

Integrate a network of practice networksIntegrate a network of practice networks Define a basic operating structure for Define a basic operating structure for

involving practices / providers in researchinvolving practices / providers in research Assess the characteristics and preferences of Assess the characteristics and preferences of

practices / providers / patients for researchpractices / providers / patients for research Expand / enhance the network over timeExpand / enhance the network over time Match community healthcare priorities with Match community healthcare priorities with

CTSI funding opportunitiesCTSI funding opportunities

Engaging Healthcare Engaging Healthcare Community - WhoCommunity - Who

Existing Practice Based Research NetworksExisting Practice Based Research Networks– INET, ResNet, PResNetINET, ResNet, PResNet– Director, coordinator, and research staffDirector, coordinator, and research staff

Practices “at large”Practices “at large”– In INPC – facilitates recruitment and data collectionIn INPC – facilitates recruitment and data collection– In other interested delivery systems – MMG, St. V…In other interested delivery systems – MMG, St. V…– Truly at large? – incorporated into existing Truly at large? – incorporated into existing

networksnetworks Polis Center – Polis Center – mapping of practices and nearby resourcesmapping of practices and nearby resources

Fostering CommunicationFostering Communication

Communication Action TeamCommunication Action Team Division of CMEDivision of CME Identify effective communication Identify effective communication

channelschannels Study the relative impact of different Study the relative impact of different

communication channels over timecommunication channels over time Bridge dialogue among stakeholdersBridge dialogue among stakeholders

SynergiesSynergies

CTSI Hub – match scientific funding CTSI Hub – match scientific funding opportunities with community opportunities with community preferencespreferences

Recruitment core – integrate Recruitment core – integrate information about all CTSI recruitment information about all CTSI recruitment channelschannels

Bio-informatics - expedite recruitment Bio-informatics - expedite recruitment in healthcare settings and enhance in healthcare settings and enhance provider roleprovider role

A Real World ExampleA Real World Example

The Diabetes Prevention ProgramThe Diabetes Prevention Program

Study InterventionsEligible participantsEligible participants

RandomizedRandomized

Standard lifestyle recommendationsStandard lifestyle recommendations

Intensive Intensive LifestyleLifestyle(n = 1079)(n = 1079)

MetforminMetformin

(n = 1073)(n = 1073)

PlaceboPlacebo

(n = 1082)(n = 1082)

TroglitazoneTroglitazone Discontinued 6/98Discontinued 6/98 (n = 585)(n = 585)

Lifestyle Intervention An intensive program with the

following specific goals:

• >> 7% 7% loss of body weight and loss of body weight and maintenance of weight lossmaintenance of weight loss

–Fat gram goal -- 25% of calories from fatFat gram goal -- 25% of calories from fat

–Calorie intake goal -- 1200-1800 kcal/dayCalorie intake goal -- 1200-1800 kcal/day

• >> 150 minutes per week of physical activity 150 minutes per week of physical activity

Metformin- 850 mg per day escalating after - 850 mg per day escalating after

4 weeks to 850 mg twice per day4 weeks to 850 mg twice per day

Placebo- Metformin placebo adjusted in Metformin placebo adjusted in

parallel with active drugsparallel with active drugs

Medication Medication InterventionIntervention

Mean Weight Change from Baseline

-8

-7

-6

-5

-4

-3

-2

-1

0

1

Wei

gh

t C

han

ge

(Kg

)

0 6 12 18 24 30 36 42 48 Months

Lifestyle

Metformin

+Placebo

0

1

2

3

4

5

6

7

8

Leis

ure

ph

ysic

al acti

vit

y c

han

ge

0 1 2 3 4

Years from randomizationYears from randomization

Mean Change in Leisure Physical Activity (Met hours

per week)Lifestyle

MetforminPlacebo

Development of Diabetes

PlaceboPlacebo MetforminMetformin Life-Life-stylestyle

Development of diabetes 11.0% 7.8% 4.8% (percent per year)

Reduction of diabetes ---- 31% 58% compared with placebo

Number needed to treat ---- 13.9 6.9 to prevent 1 case in 3 yrs

So What do we So What do we Need to do to Need to do to

Prevent Diabetes Prevent Diabetes in the “Real in the “Real

World?”World?”

DPP TranslationDPP Translation

Population-Level

Diabetes Prevention

Evidence-base

Real-World Implementati

on

Linked to healthcare

Adaptable to different settings

Factor access issues

Scalable nationally

Worth the investment

Health Payers

Employers

Individuals

Evidence-based Diabetes Evidence-based Diabetes PreventionPrevention

Evidence / goal Healthcare Community

Target adults with pre-diabetes (blood test)

X

Provide structured lifestyle intervention to achieve 5-7% weight loss

X

Link to health plan / employer payment (physician initiated)

X

Provide ongoing behavior support at least monthly

X

Partnered Approach for Partnered Approach for PreventionPrevention

Healthcare

Glucose testingRisk/benefit assessment (safe?)Prescriptive advice (role for meds?)Gateway to reimbursement

Formal Programs

CommunityPopulation ResourcesPopulation Resources

EnvironmentEnvironment

Education by Schools & Media Education by Schools & Media

Risk assessment opportunitiesRisk assessment opportunities

Reciprocal Reciprocal InteractionInteractionss PersonnelPersonnel

ExperienceExperience

FacilitiesFacilities

ContactContact

The YMCA modelThe YMCA model

What is the YMCA?What is the YMCA? Community-based organizationCommunity-based organization Started in 1800’s in the United Started in 1800’s in the United

KingdomKingdom Found in 98 countriesFound in 98 countries Focus on developing mind, body and Focus on developing mind, body and

spirit:spirit:– Place for social, health and athletic Place for social, health and athletic

activitiesactivities– Largest provider of child care in the Largest provider of child care in the

United StatesUnited States

Why the YMCA?Why the YMCA? 2,600 YMCAs in the U.S.2,600 YMCAs in the U.S. 42M U.S. families within 3 miles of a Y42M U.S. families within 3 miles of a Y Strong history of disseminating Strong history of disseminating

structured clinical interventions structured clinical interventions nationallynationally

Operate to achieve cost recovery onlyOperate to achieve cost recovery only Policy to turn no person away for Policy to turn no person away for

inability to pay for a program (financial inability to pay for a program (financial assistance)assistance)

Group Delivery of DPPGroup Delivery of DPP Offer program to a group of 10 – 12 led Offer program to a group of 10 – 12 led

by trained lay personsby trained lay persons Enhances social support and Enhances social support and

accountabilityaccountability Lowers direct intervention costs by >75%Lowers direct intervention costs by >75% Cost-saving for a health plan that shares Cost-saving for a health plan that shares

45-50% of intervention fees with other 45-50% of intervention fees with other payers/purchaserspayers/purchasers

The DEPLOY Study The DEPLOY Study

Community-based pilot RCTCommunity-based pilot RCT Test the feasibility and effectiveness Test the feasibility and effectiveness

of training YMCA employees to of training YMCA employees to deliver a group-based version of the deliver a group-based version of the DPP lifestyle intervention in YMCA DPP lifestyle intervention in YMCA branch facilitiesbranch facilities

Results after 4-6 Results after 4-6 monthsmonths

Brief Advice(N = 38)

DPP(N = 39)

p-value*

Weight (%reduction) -2.0%-2.0% -6.0%-6.0% <0.001

Change SBP (mmHg) -2.3 -1.9 0.88

Change A1c (%) -0.1 -0.1 0.96

Change TChol (mg/dL) +6.0+6.0 -21.6-21.6 <0.001

Change HDL (mg/dL) +2.1 +1.1 0.68

* Adjusted for sex and baseline value of outcome variable

Results after 12-14 Results after 12-14 monthsmonths

Brief Advice(N = 33)

DPP(N = 29)

p-value*

Weight (%reduction) -1.8%-1.8% -6.0%-6.0% 0.008

Change SBP (mmHg) -2.7 -1.6 0.78

Change A1c (%) +0.03 -0.1 0.28

Change TChol (mg/dL) +11.8+11.8 -13.5-13.5 0.002

Change HDL (mg/dL) -1.4 +1.9 0.10

* Adjusted for sex and baseline value of outcome variable