1. Providing Diabetes Care For The Uninsured DPAC Full Membership Meeting April 27, 2009 Kellogg Conference Center, East Lansing, MI Peter Dews M.D., M.S.

2. Health disparities are differences in the incidence, prevalence, mortality, burden of diseases and other adverse health conditions or outcomes that exist among specific population groups in the United States. In Michigan, as in the United States, racial and ethnic minority populations carry a disproportionately heavy burden from health disparities. This burden is manifested in increased risk for disease, delayed diagnosis, inaccessible and inadequate care, poor health outcomes and premature death, much of which is preventable. What are Health Disparities? MDCH, Health Disparities Report, 2008, 2.16.09

3. Insurance Coverage May Reduce Disparities in Cardiovascular Disease and Diabetes Management April 21, 2009 - A Commonwealth Fund- supported study in the Annals of Internal Medicine found that Medicare coverage reduces racial, ethnic, and socioeconomic disparities in heart disease and diabetes outcomes. The authors suggested that providing health coverage to those under age 65 may reduce such disparities among all adults. Breaking News…………………

4. Contribution To measure changes in chronic disease control, the authors used blood pressure, hemoglobin A1c, and total cholesterol measurements that were obtained from participants in the 1999 to 2006 National Health and Nutrition Examination Survey. Disease control improved over 8 years, but gaps between white and nonwhite patients did not change. The gaps were smaller after age 65 years, when universal Medicare insurance begins. Insurance Coverage May Reduce Disparities in Cardiovascular Disease and Diabetes Management 21 April 2009 Annals of Internal Medicine Volume 150 Number 8 515

5. Context Acquiring health insurance and getting better quality of care could reduce health care disparities. The relative importance of these 2 factors is unknown. Insurance Coverage May Reduce Disparities in Cardiovascular Disease and Diabetes Management 21 April 2009 Annals of Internal Medicine Volume 150 Number 8 515

6. Meanwhile, down here on the ground…………..

7. Brightmoor From Wikipedia, the free encyclopedia 'Brightmoor' is a neighborhood in Detroit, Michigan, United States. Composed of mostly low-grade housing, Brightmoor was first populated by poor whites from Appalachia. The area is still home to a remnant population of extremely few poor whites. Brightmoor is one of the most desolate and poorest neighborhoods in Detroit.DetroitMichiganUnited StatesAppalachia Brightmoor was created in the early 1900s by Henry Ford as a neighborhood for his factory workers. The area has been affected economically by the overall reduction in automotive industry jobs in the region. Consequently, the poverty rate is 44% in the neighborhood, compared to a 32% average for the rest of Detroit. It’s all about spin!!!!!!!!

8. Brightmoor is a community of 19,837 residents in Northwest Detroit and is bordered on the west by Telegraph Road, Eliza Howell Park and the Rouge River and on the East roughly by Evergreen Road with a Southern section between Evergreen and Southfield Roads. It is situated entirely within the 48223 zip code area. Development of Brightmoor began in the early 1920s when B.E. Taylor bought 160 acres of land in 1921, one mile from the Detroit city limits. He opened the Brightmoor Subdivision in 1922. Brightmoor grew quickly with an additional 2,913 acres added from 1923 to 1924. In 1926 it was annexed by the city of Detroit. The population of Brightmoor was primarily working class families that supported the auto industry. Welcome to the Brightmoor community web site. We are a neighborhood in the North-West of Detroit and are proud to have been chosen as a "Good Neighborhood" by the Skillman Foundation.Skillman Foundation It’s all about spin!!!!!!!!

9. Income and Poverty

11. Challenges to Quality (Diabetes) Care  Staff Turnover (providers, managers, staff)  ‘Specialty’ Care, & Services (Opinions easier to come by, than ‘stuff’)  ‘Environment’ (opportunity to ‘re- design’ Fenkell street & surrounding area)

12. Responses to Challenges to Quality (Diabetes) Care  Staff Turnover ( learning environment)  ‘Specialty’ Care, & Services (Broadened professional scope, Physicians Who Care, network)  ‘Environment’ (community partnerships, like Skillman foundation)

13. ‘Process, Structure, Outcomes’  Structure (social worker, processes Patient Assistance Program forms for medications, 10-15% un- retrieved). Estimated 10-12 hours a week on forms alone. (www.needymeds.com).www.needymeds.com 340 B Pharmacy, but emphasize $4 Rx programs (Dietician / CDE from city health department rotates across sites. Estimates return follow up rates < 50%) Establishing group visits, 30% ‘open access’ scheduling. Planned visits

15.  Process (‘Low Tech’ chronic condition charting) Attention to consensus guidelines Align staff incentives with those of Physicians, NP’s. Selective on site HbA1c determination ‘Process, Structure, Outcomes’

18. ‘ evidence suggests that quality of care has improved in the past decade, however quality improvement may not necessarily lead to more equitable care especially if improvements occur among providers who serve fewer disadvantaged patients’ ‘Racial and ethnic minorities and adults of lower socioeconomic status are much more likely to be uninsured and uninsured adults are much less likely to receive basic clinical services for these (chronic) conditions’ Now I know what it does!