Strategies Addressing Chronic Disease

Prediabetes is a condition in which blood sugar is high, but not high enough to be considered type 2 diabetes. It is reversible, unlike type 1 diabetes. People diagnosed with prediabetes who lose 5-7% of their body weight decrease their risk of developing type 2 diabetes by 58%, and by 71% if they are over the age of 60. Lifestyle change programs like the National Diabetes Prevention Program can help those diagnosed with prediabetes to lose weight and lower their risk.

Prediabetes – Your Chance to Prevent Type 2 Diabetes

How CDPP is addressing Prediabetes:

1.  Increase enrollment and retention of priority populations in the National Diabetes Prevention Program (National DPP) lifestyle intervention and the Medicare DPP by improving access, appropriateness, and feasibility of the programs.
2.  Support the development of multi-directional e-referral systems that support electronic exchange of information between health care and community based organizations.
3.  Improve the capacity of the diabetes workforce to address factors related to the social determinants of health that impact health outcomes for priority populations with and at risk for diabetes.

Diabetes mellitus is a condition in which blood sugar levels are elevated over a period of time. It can cause many complications, including heart disease, stroke, kidney disease, limb loss, and blindness. There are three main types of diabetes.

• Type 1 diabetes: Occurs when the pancreas does not produce enough insulin. The cause is unknown.
• Type 2 diabetes: Occurs when cells fail to respond to insulin properly, which may lead to inadequate insulin production. It is the most common type of diabetes, and its primary causes are overweight or obesity and inadequate physical activity.
• Gestational diabetes: Occurs when pregnant women without a history of diabetes experience high blood sugar levels.

While everyone with diabetes can benefit from medically-assisted diet and exercise to help control blood sugar, type 2 diabetes is usually preventable with a healthy lifestyle. Preventing or delaying the onset of type 2 diabetes can significantly reduce medical costs and improve quality of life.

Diabetes Basics

How CDPP is addressing diabetes:

1.  Strengthen self-care practices by improving access, appropriateness, and feasibility of diabetes self-management education and support (DSMES) services for priority populations.
2.  Improve acceptability and quality of care for priority populations with diabetes.
3.  Support the development of multi-directional e-referral systems that support electronic exchange of information between health care and community based organizations.
4.  Improve the capacity of the diabetes workforce to address factors related to the social determinants of health that impact health outcomes for priority populations with and at risk for diabetes.
5.  Implement, spread, and sustain one of the following evidence-based, family-centered childhood obesity interventions: 1) Mind, Exercise, Nutrition…Do it!; 2) Family Based Behavioral Therapy; 3) Bright Bodies; and 4) Healthy Weight and Your Child.

Heart disease is the leading cause of death in the United States. The most common type of cardiovascular disease in the US is coronary artery disease, which can cause heart attacks and death. High blood pressure, high cholesterol, diabetes, and being overweight or obese are all risk factors for heart disease. Heart disease can be delayed or prevented with diet, exercise, not smoking, and with medicine, if necessary.

About Heart Disease

How CDPP is addressing heart disease and stroke:

1.  Advance the adoption and use of electronic health records or health information technology to identify, track, and monitor measures for clinical and social services and support needs to address health care disparities and health outcomes for adults at highest risk of cardiovascular disease (CVD).
2.  Promote the use of standardized processes or tools to identify the social services and support needs of patient populations at highest risk of CVD, with a focus on hypertension and high cholesterol, and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc.
3.  Advance the use of health information systems that support team-based care to monitor population health with a focus on health disparities, hypertension, and high cholesterol.
4.  Assemble or create multidisciplinary teams (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers, and community-based workers) to identify patients’ social services and support needs and to improve the management and treatment of hypertension and high cholesterol.
5.  Build and manage a coordinated network of multidisciplinary partnerships that address identified barriers to social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing) within populations at highest risk of CVD.
6.  Create and enhance community-clinical links to identify social determinants of health (e.g., inferior housing, lack of transportation, inadequate access to care, and limited community resources) and respond to the social services and support needs of populations at highest risk of CVD with a focus on hypertension and high cholesterol.
7.  Identify and deploy dedicated community health workers (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes.
8.  Promote use of self-measured blood pressure monitoring with clinical support within populations at highest risk of hypertension.