Rhode island advancing health equity for priority populations with or at risk for diabetes - rhode island department of health's (ridoh) diabetes, heart disease and stroke (ridhds) program is…

Rhode island advancing health equity for priority populations with or at risk for diabetes - rhode island department of health's (ridoh) diabetes, heart disease and stroke (ridhds) program is centrally located at 3 capitol hill in providence, RI, 02908. Ridoh is committed and is fully capable to serving all populations and communities within the state to provide every person living in rhode island with an equal opportunity to be as healthy as possible. The ridhds is further committed to addressing chronic disease statewide and will utilize funding opportunity CDC-RFA-DP23-0020 (component a) to build upon the accomplishments achieved in DP18-1815 and DP18-1817. Ridhds will concentrate efforts on extending evidence-based strategies and implementing new strategies and activities, aimed at preventing and managing diabetes in high-burden populations. Ridhds has identified as its priority population adults who are below 400% of the federal poverty level, who are at heightened risk for both development and poor control of diabetes. An additional emphasis will be placed on reducing racial and ethnic disparities throughout the state. Ridhds is organized into two main areas of work: (1) health systems transformation (HST) and (2) scaling and sustaining evidence-based lifestyle change programs (eblps) through partnerships, referrals systems, and innovative payment models. Ridhds will address the diabetes risk, burden, and complications for priority populations by focusing on a comprehensive, statewide approach. Ridhds will leverage partnerships within health systems to improve quality of care and outcomes for patients with diabetes through screening and early detection. Additionally, ridhds will continue operations of the community health network (CHN) as a referral system for eblps and expand its capabilities to provide bidirectional feedback of patient outcomes, participant barriers and social determinant of health (sdoh) needs, and billing for innovative payment models that sustain the CHN, its eblps, and related programs and services. Ridhds will simultaneously build on the success of current initiatives to advance clinical-community linkages that address system or population-level needs related to the sdohs and strengthen the community health worker workforce by offering training opportunities that support and expand their involvement in eblps and related reimbursement. Lastly, ridhds will scale the delivery of the national diabetes prevention program (national DPP) through existing and new partnerships statewide and implement payment models that sustain national DPP alongside other eblps. The approach taken by ridhds will lead to the following outcomes by the end of the project period: (1) increased number of organizations implementing evidence-based community behavior change programs; (2) increased adaptation/tailoring of effective programs for priority populations; (3) increased participation in evidence-based community behavioral programs; (4) increased number of patients screened and referred to community resources; (5) increased sdoh screenings in clinical settings; (6) increased multi-directional communications between clinical and community resources; (7) decreased proportion of people with diabetes with an A1C>9; and (8) increased number of program completers served by CDC recognized national DPP delivery organizations who reduce their risk for type 2 diabetes.