United States

31 patients had one or more follow-up visits with a blood glucose measurement and nine patients had their blood glucose levels under control (RBS <= 7.8 mmol/L) at the time of their most recent blood glucose measurement (Figure 10). Disaggregated counts by sex for each category are available in Appendix D.

Figure 10. Pixley ka Semecascade of care

United States Ramsey County

One of the key challenges Regions faced was retaining enrollees. Regions lost a significant number to followup within the first six months of program implementation (100% of initial enrollees within the first three months; 88% of a second group of enrollees during the fourth through sixth months). Most withdrawals were those aged between 45 and 59 years with public/state insurance.

Regions Hospital had a combined enrollment of 78 patients; 33 patients were enrolled for hypertension, and 69 patients were enrolled for diabetes. Females slightly outnumbered males for enrollment for both hypertension and diabetes. Appendix D contains counts for enrollment and disease control for both diabetes and hypertension disaggregated by sex.

Figure 11 . Ramsey Countycascade of care

Among 33 individuals enrolled in HealthRise with a diagnosis of hypertension, 21 individuals had multiple blood pressure readings, permitting assessment of changes in blood pressure over time. Based on changes between the first and last available blood pressure measurement for each patient since enrollment in the program, 10 individuals displayed reductions in blood pressure and moved to a lower blood pressure category. (Blood pressure categories considered were: SBP < 140 mmHg and DBP < 90 mmHg; SBP ≥ 140 mmHg to SBP < 160 mmHg and DBP ≥ 90 mmHg to DBP < 100 mmHg; SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). The average change in blood pressure for these individuals was -21.54 (95% CI: -28.42, -12.15).

Among individuals with multiple blood pressure readings, 10 patients had their blood pressure under control (SBP < 140 mmHg and DBP < 90 mmHg) as of their most recent available measurement (Figure 11).

Among 69 individuals enrolled in the HealthRise program with a diagnosis of diabetes, 42 individuals had multiple A1c measurements, allowing us to evaluate change in blood glucose over time. Based on changes between the earliest and most recent available A1c measurement for each patient since enrollment in the program, 13 individuals displayed reductions in A1c readings and moved to a lower blood glucose category. (A1c blood glucose categories considered are: <7%, 7%–7.9%, 8%–9.9%, and ≥10%). The average change in A1c values for these individuals was -2.22 (95% CI: -2.69, -1.48).

Among all individuals enrolled in the HealthRise program with a diagnosis of diabetes, 12 patients had their blood glucose under control (A1c < 8%) as of their most recent available measurement (Figure 11).

Hennepin County

Pillsbury encountered difficulties encouraging individuals to enroll in the program. Only six patients enrolled at the start of the program, of which four withdrew within the first three months. Throughout the program, Pillsbury had a combined enrollment of 121 patients, where 102 patients were enrolled for hypertension and

100 were enrolled for diabetes. Appendix D contains counts disaggregated by sex for enrollment and disease control for both hypertension and diabetes.

Figure 12. Hennepin Countycascade of care

Among 102 individuals with a diagnosis of hypertension, the progress of 72 individuals can be reported based on multiple blood pressure measurements. Since enrollment in the program, 21 of these 72 individuals showed a sufficient reduction in blood pressure to transition to a lower blood pressure category. (Blood pressure categories considered were: SBP < 140 mmHg and DBP < 90 mmHg; SBP ≥ 140 mmHg to SBP < 160 mmHg and DBP ≥ 90 mmHg to DBP < 100 mmHg; SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). The average change in blood pressure among these 21 patients was -13.44 (95% CI: -16.42, -10.46).

55 of the 72 individuals with multiple blood pressure measurements had their blood pressure under control (SBP < 140 mmHg and DBP < 90 mmHg) at the time of the most recent available reading (Figure 12).

Among 100 individuals with a diagnosis corresponding to diabetes, the progress of 54 individuals can be reported based on multiple A1c measurements. Since enrollment, 22 of these 54 individuals showed a sufficient reduction in blood glucose to transition to a lower blood glucose category. ((A1c blood glucose categories considered are: <7%, 7%–7.9%, 8%–9.9%, and ≥10%). Among those individuals who moved to a lower A1c category, the average change in A1c measurement was -1.87 (95% CI: -2.37, -1.36).

26 of the 54 individuals with multiple A1c measurements available had their blood glucose levels under control (A1c < 8%) at the time of their most recent available measurement (Figure 12).

North Market in North Minneapolis – considered a food desert – provided a full-service grocery store, a center for wellness services, and a community gathering place, all under a single roof. A variety of classes, ranging from cardio kickboxing, Zumba, boot camp, meal prep, yoga, and mindfulness, to grocery store tours, were offered between December 2017 and July 2018. A total of 214 classes were offered, in which 1,965 individuals participated. A total of 479 unique participants were recorded to have attended these classes.

North Market retained approximately 13% of total participants. The graphic below visualizes the number of participants in each of the classes between December 2017 and May 2018 (Figure 13).

Figure 13. North Market class attendance over time

Rice County

HealthFinders Collaborative faced challenges enrolling patients, with no patients opting to enroll in HealthRise in the first six months of project implementation. However, following these initial difficulties, they were successful in retaining all the patients who enrolled in the program at a later time, for the duration of the program. Among the 208 patients enrolled in the HFC program, 191 individuals were identified with diagnoses of hypertension, diabetes, or both based on ICD codes provided by HFC.

Figure 14. Rice Countycascade of care

Among 87 individuals with a diagnosis corresponding to hypertension, the progress of 76 individuals can be reported based on multiple blood pressure measurements. Of these 76 individuals, since enrollment in the program, 23 have had reductions in blood pressure such that they transitioned to a lower blood pressure category. (Blood pressure categories considered were: SBP < 140 mmHg and DBP < 90 mmHg; SBP ≥ 140 mmHg to SBP < 160 mmHg and DBP ≥ 90 mmHg to DBP < 100 mmHg; SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). The average change in blood pressure among individuals who transitioned to a lower blood pressure category was -9.75 (95% CI: -11.88, -7.62).

Among individuals enrolled in the HealthRise program with a diagnoses of hypertension who had two or more blood pressure readings available, a total of 45 individuals had controlled levels of blood pressure (SBP < 140 mmHg and DBP < 90 mmHg) according to their most recently available blood pressure reading (Figure 14).

Among the 149 individuals with a diagnosis corresponding to diabetes, the progress of 108 individuals can be reported based on multiple A1c measurements. Of those 108 individuals, since enrollment in the program, 31 have had reductions in blood glucose levels resulting in a transition to a lower blood glucose category. (A1c blood glucose categories considered are: <7%, 7%–7.9%, 8%–9.9%, and ≥10%). Among individuals who transitioned to a lower A1c category, the average change in A1c level was -1.78 (95% CI: -2.25, -1.32).

Among individuals enrolled in the HealthRise program with a diagnoses of diabetes who had two or more blood glucose readings available, a total of 53 individuals had controlled levels of blood glucose (A1c < 8%) according to their most recent available blood glucose measurement (Figure 14).

Appendix D contains counts disaggregated by sex for enrollment and disease control for both hypertension and diabetes.