1. Chronic Disease Update
Rowe Hudson
Champion

2. Chronic Disease
With community partners, develop community/neighborhood clinics for chronic disease prevention, education, management, such as sickle cell, diabetes, obesity, hypertension and asthma. Target populations with greatest need (e.g., African Americans for diabetes).

3. Chronic Disease - Scorecard
Prevalence of Diabetes
Goal is to reach Florida average. Lee County has improved but still is slightly above, although statistically similar to both Florida and the U.S. There is no HP 2020 specific goal that aligns.
ED Diabetes Diagnosis
Goal Champions identified this data from all LMHS hospital Emergency Departments as the primary indicator if Diabetes is being well managed in our community. Goal is to see no increase in ED visits.

4. Asthma - Scorecard Prevalence of Asthma
Goal is to have no increase in diagnosed asthma cases. The reported numbers have seen much variation over the years. As of 2014 we were similar to Florida and the U. S.
ED Asthma Diagnosis
Champions identified this data from LMHS hospital emergency departments as a key indicator. The goal is to see no increase, however we continue to see significant increases in ED use.

5. Chronic Health Programs
Chronic Disease Self-Management Program - “It’s All About You”
Chronic Pain Self-Management Program
Lee Health Solutions
Diabetes Education Program
Weight Management Program
Obesity Clinic at Lee Community Healthcare
Lee Community Healthcare
SKY Family YMCA Diabetes Collaboration
Living With Diabetes (21st Century Collaborative)
Family Health Centers of Southwest Florida

6. Accomplishments Chronic Disease Self-Management Program
41 Active Leaders
365 Participants Completed Program
Increased variety of community partners
ED Visit Decrease: 20% (2014) / 31% (2015)
Lee Weight Management Program
Total Participants: 3226 (2016)
Pounds Lost in 30 Days: 5 lbs (2016)
Pounds Lost in 3 Months: 12 lbs (2016)
Average 6% Body Weight Lost in 3 Months
(Goal: 5-10%)
It’s All About You - CDSMP: Decrease in active leaders due to change in LPG case manager job responsibilities.
Additional leader training in 2015 – Expect a minimum of 12 additional leaders by the end of this year.
Community Partners: Assisted and Independent Living facilities (Cypress Cove, Brookdale College Parkway and Cape Coral, St John’s Villas, Shell Point), Hope Pace, Lighthouse of SWFL, Libraries (Cape Coral, Fort Myers, Estero), Cross Creek Estates, Deltura Country Club, Bonita Bay, Center for Independent Living, Wellness Center of Cape Coral, Pine Echo Community (Spanish workshop), Right At Home Office Bonita, Good Shepard, Faith Presbyterian, Chapel By the Sea faith communities.
Lee Weight Management Program:
30 Day Weight Loss: 5 lbs (2014) / 6 lbs (2015)
3 Month Weight Loss: 11 lbs (2014) / 13 lbs (2015)
Average of 7% weight lost in first 3 months of program (Goal: 5-10% of weight)
Decrease in patient volume due to one dietitian position being vacant for 5 months.
Diabetes Program:
Both years remained constant. 3 Month goal was achieved (A1C 6.9%)
Hemoglobin A1C Goal: < 7.0%

7. Accomplishments Chronic Pain Self-Management Program
New program in April 2016
Fulfills tremendous need in community
17 Active leaders June 2016
Diabetes Education Program (Lee Health Solutions)
Participants: 845 (2016)
Initial Hemoglobin A1C: 7.5% (2016)
3 Month A1C: 6.8% (2016)

8. Accomplishments In 2015 Patients with Chronic Disease improved
62% of diabetic patients improved A1C at or below target levels (vs. 57% in 2013)
64% of hypertensive patients reduced blood pressure to 140/90 (vs. 61% in 2013)
75% of chronic asthma patients controlled with medications (vs. 69% in 2013)
83 % of patients with ischemic vascular disease maintained prescribed aspirin/other therapy (vs. 77% in 2013)
Obesity Clinic – Dietitian available at all 3 LCH locations.

9. Accomplishments
SKY Family YMCA Diabetes Prevention Collaboration (Bonita)
HHS concluded that the diabetes prevention program led to cost savings (Medicare)
HHS conclusion opens the door toward eventual program coverage for pre-diabetes patients
SKY Family YMCA was one of 17 Y’s nation-wide to participate in the demonstration project
Family Health Centers of Southwest Florida
Educated 1774 people with Metabolic Syndrome, of which 501 women had Gestational Diabetes
Smoking Cessation classes were completed
Homeless intervention -75 clients seen for education, and personal hygiene items were distributed with the support from Cape Coral Kiwanis partnership
Childhood Obesity program “Quests for Kid’s Health” children given education

10. Mt. Hermon Health Services Ministry Goals
To provide Personal Health Counseling
To provide Health Education
To provide Health Care Advocacy
To bring wellness to the congregation based on the belief that health is growth towards well-being of the mind, body and spirit. Developed to help individuals stay well and tailors its health related activities to meet the desires and needs of the congregation and the community at large.
Health Services Mission

11. “Living with Diabetes” Saturday, July 23, 2016
Lee Memorial Health System
Family Health Centers
Nova Nordisk
Mt. Hermon Ministries
Department of Health
Harry Chapin Food Bank
Healthy Lee
Guest Speaker
Dominique Wilkins
NBA All-Star

12. Event Focus EDUCATION SCREENING HEALTHY FOOD DISTRIBUTION BLOOD SUGAR
BLOOD PRESSURE
FOOT HEALTH
VISION
HEALTHY FOOD DISTRIBUTION

13. Chronic Disease Management Discussion