The Durham Diabetes Coalition
Location: Durham County, North Carolina
The Durham Diabetes Coalition is committed to improving population-level health outcomes and quality of life for adults suffering from type 2 diabetes and at the same time sought to reduce disparities in health outcomes. Through a specially enabled informatics system, visual maps revealed disproportion in the prevalence of diabetes among Durham County residents. Through this innovative system, patients of high need were identified and interventions were then implemented to meet the specific needs of patients. Using data from Duke University Health System, 14,345 unique patients were identified. A risk algorithm was used to distribute patients into low, moderate, or high-risk groups and guide the appropriate interventions in combination with recommendations from providers. During the Together on Diabetes project period, the informatics system allowed for real-time monitoring of individuals and populations with type diabetes, allowing for data-driven decision-making.
- Developing the risk algorithm that places patients into low, moderate, or high-risk groups and guides interventions for patients in conjunction with recommendations from providers allowed for tailoring the intervention based on patient needs.
- Willingness to be innovative and think outside the box to implement a range of interventions for high, moderate, and low risk diabetes patients.
- Meeting people “where they are” (e.g., home, community buildings, church, salons, parks, etc.) and being receptive to different viewpoints was important in assuring continued participation.
- On-going communications and group meetings with health care, informatics, and public health staff as well as community partners, patients living with diabetes, and project leadership allowed for new and modified intervention components.
- A marvelous community advisory board and strong collaborative partnerships allowed for data-driven and community-driven interventions.