1. WWW.DIABETESHEALTHEQUITY.ORG HOUSEKEEPING TIPS Microphones will be muted by the host Please note the audio and video controls in the top left corner If you would like to ask questions during the question and answer session, please type them in the chat box at the bottom right hand of your screen as pictured below Chat Box Audio & Video controls

2. WWW.DIABETESHEALTHEQUITY.ORG TYING IT ALL TOGETHER – THE 3-ELEMENT MODEL REALIZED “ A Virtual Exploration of the 3-Element Approach for Achieving Diabetes Health Equity”

3. WWW.DIABETESHEALTHEQUITY.ORG TYING IT ALL TOGETHER – THE 3-ELEMENT MODEL REALIZED “ A Virtual Exploration of the 3-Element Approach for Achieving Diabetes Health Equity”

4. WWW.DIABETESHEALTHEQUITY.ORG TYING IT ALL TOGETHER IN A RAPID-CYCLE IMPROVEMENT PROCESS How Do We Tie it All Together? Can we do rapid-cycle feedback on outcomes and continuously improve interventions in each domain and in the spaces in- between the patient and the practice, or between the practice and the community or between the hospital and home, with a health equity coalition all working together to keep improving connections and processes and outcomes until we eliminate disparities? Clinic (PCMH) Home & Community Outcomes (Hospital Bed- Days, Disability, Death) 1 1 2 2 3 3 4 4 5 5 7 7 6 6

5. WWW.DIABETESHEALTHEQUITY.ORG MODERATOR GEORGE RUST, MD, MPH CO-DIRECTOR, NATIONAL CENTER FOR PRIMARY CARE

6. WWW.DIABETESHEALTHEQUITY.ORG Tying It All Together – The 3-Element Model Realized What: Serving as the best practice, the Southcentral Foundation and the Camden Coalition will share their parellel experiences and success stores in using the 3-Element Model of integrating clinic, community and data driven interventions To change the health system and improve the overall health of two underserved cities.

7. WWW.DIABETESHEALTHEQUITY.ORG STEVEN KAUFMAN, MD STAFF ENDOCRINOLOGIST, CAMDEN COALITION OF HEALTHCARE PROVIDERS DEPUTY MEDICAL DIRECTOR, URBAN HEALTH INSTITUTE

8. WWW.DIABETESHEALTHEQUITY.ORG

9. Camden City Median Family Income: $29,118 36% below Federal Poverty Level 48% Black, 47% Hispanic Camden County Median Family Income: $57,429 11% below the Federal Poverty Level 21% Black, 14% Hispanic NEED FOR LOCAL DATA

10. WWW.DIABETESHEALTHEQUITY.ORG CAMDEN HIE

11. WWW.DIABETESHEALTHEQUITY.ORG CAMDEN RESIDENTS ARE TWICE AS LIKELY TO USE THE EMERGENCY DEPARTMENT

12. WWW.DIABETESHEALTHEQUITY.ORG COST ARE CONCENTRATED BY GEOGRAPHY AS WELL 6% of city blocks account for 18% of the patients, 27% of the visits, and 37% of receipts. Several buildings in the city are responsible for between $1 and $3 million in hospital costs each year.

13. WWW.DIABETESHEALTHEQUITY.ORG

16. STEVE TIERNEY, MD, CMIO MEDICAL DIRECTOR OF QUALITY IMPROVEMENT SOUTHCENTRAL FOUNDATION

17. WWW.DIABETESHEALTHEQUITY.ORG Alaska Native People Shaping Health Care Southcentral Foundation Nuka System of Care New Directions in the Assessment of Community Health and Organizational Redesign Copyright © 2011 Southcentral Foundation. All Rights Reserved. NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law. This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher.

18. WWW.DIABETESHEALTHEQUITY.ORG APPROACH TO CHANGE IS INFLUENCED BY PROSPECTIVE Copyright © 2011 Southcentral Foundation. All Rights Reserved.

19. WWW.DIABETESHEALTHEQUITY.ORG CHANGING PROSPECTIVE CAN ALTER APPROACH TO CHANGE Copyright © 2011 Southcentral Foundation. All Rights Reserved.

20. WWW.DIABETESHEALTHEQUITY.ORG INTERACTIVE CONDITION CENTERED ACTION LISTS FOR ALL METRICS Fictitious Customer Owner Info

21. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

22. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

23. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

24. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

25. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

26. WWW.DIABETESHEALTHEQUITY.ORG WHAT DOES THIS MAKE YOU WANT TO KNOW?

27. WWW.DIABETESHEALTHEQUITY.ORG Copyright © 2011 Southcentral Foundation. All Rights Reserved.

28. WWW.DIABETESHEALTHEQUITY.ORG CDR PROFILE Copyright © 2011 Southcentral Foundation. All Rights Reserved.

29. WWW.DIABETESHEALTHEQUITY.ORG DISCUSSION Please use your chat box in the bottom right hand corner

30. WWW.DIABETESHEALTHEQUITY.ORG COMMERCIAL BREAK & ANNOUNCENMENTS

31. WWW.DIABETESHEALTHEQUITY.ORG QUESTIONS FROM THE AUDIENCE Please use your chat box in the bottom right hand corner. Mic will be enabled when moderator calls on you.

32. WWW.DIABETESHEALTHEQUITY.ORG THANK YOU FOR PARTICIPATING Please assist us by completing the post survey for this training. The link is located in the chat box to the bottom right of your screen. This webinar series is funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.