Full Project Name:Population Health Improvement: Research and education to help patients and employees with diabetes or cancerPrincipal Investigator:John Meurer, MD, MBA, Institute for Health and EquityCo-Investigator:Laura Cassidy, PhD, Institute for Health Equity; Sergey Tarima, PhD, Institute for Health Equity; Staci Young, PhD, Department of Family and Community Medicine; Rodney Sparapani, PhD; Institute for Health EquityAward Amount:$1,800,000Project Duration:48 months
Project Description Narrative:
Diabetes is a significant health and societal problem, affecting more than 26 million Americans while another 79 million have pre-diabetes. Despite prevention and treatment options, many individuals lack education, motivation, and/or support in modifying their lifestyles to reduce their risk. New methods of care coordination, cost reduction, and patient health management must be explored. This project aims to establish a research infrastructure to improve population health, initially focusing on diabetes control for patients and employees by studying new methods for better coordinated, patient-centered care to ultimately increase affordable, equitable access to quality services.
Outcomes & Lessons Learned:
• Successfully completed research studies, reinforcing the values that ambulatory clinic and community interventions to prevent diabetes and improve self-management can significantly improve well-being and reduce health care costs • Conducted focus groups of patients and employees to better understand challenges in self-management, clinical care, and communication needs. Focus group themes were used to guide research approaches and inform systems improvements, and documented improvements at a pilot site • Established collaborations with employee benefits groups, community agencies, and health care system providers to analyze pharmacy, billing, and clinical data to characterize quality, outcomes, and costs of diabetes care, using preliminary data to guide study design • Advanced the field of predicting diabetes outcomes for large clinical populations, studying clinical records of more than 10,000 patients to identify opportunities to predict groups more likely to improve and those more at risk for complications • Developed medical education opportunities in the science of health care delivery and population health management for MCW students, as well as a new certificate in Community Health Needs Assessment and planning • Disseminated findings and new knowledge produced in numerous journals and professional presentations in diverse areas such as population health management, sociology, ethics, diabetes self-management, ambulatory care, bariatric surgery, and sleep medicine