Joseph West, ScD Steven Whitman, PhD Lynda Stinson, MPH August 1, 2013
Sinai Urban Health Institute | Lawndale Diabetes Project
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Introduction
Diabetes is taking a toll on some of Chicago’s poorest neighborhoods. Two communities in particular, North and South Lawndale, have some of the highest diabetes prevalence and mortality rates in the city of Chicago. Sinai Health System seeks to improve the health of all Chicago residents. However, North and South Lawndale are Sinai Health System’s closest neighbors. This elevates our concern for these communities and heightens our need to better understand the underlying causes of such high rates and work towards ways to improve diabetes related health outcomes. A recent Sinai Urban Health Institute (SUHI) study in North Lawndale found a 29% prevalence of type 2 diabetes and a diabetes-related mortality rate 62% higher than for the U.S. and 37% higher than for Chicago. In South Lawndale recent data has shown a 20% prevalence of type 2 diabetes. In an effort to help residents in these two communities better manage their type 2 diabetes SUHI along with Blue Cross and Blue Shield of Illinois (BCBSIL) launched the Lawndale Diabetes Project (LDP) in 2011.
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Since then BCBSIL has committed $1.2 million to the Lawndale Diabetes Project (LDP). Over the past two years SUHI has worked with the North and South Lawndale communities to fight diabetes through outreach, education and improved access to clinical care. This report highlights the achievements of this work over the past two years. Sinai Urban Health Institute | Lawndale Diabetes Project
Sinai Health System Integrated Diabetes Care
Primary Care Physician • Clinical care expert • Medical home designee • Pharmacist and social worker referrals Nurse Team • Clinical care coordination • Primary clinical contact for patients
Community Health Educator
Community-Based Patient Assistance • Transportation arrangement • Appointment reminders • Community health resources • Caregiver assistance • Home services • Phone calls to patients Diabetes Self-Management Education • Self-testing • Emotional health • Routine clinical visits • Medication adherance
Integrated diabetes care identifies and addresses socio-environmental and nonclinical concerns. Improving communication and care coordination between clinical practitioners (i.e., primary care physicians, nurses, case managers), community resource specialists (i.e., pharmacists, social workers) and community health educators can improve clinical outcomes. This may be especially true for patients at high-risk for recurrent emergency department visits and frequent readmission due to poor chronic disease management. Action plans between patients and care team are an important tool for better communication, coordination and learning.
Sinai Urban Health Institute | Lawndale Diabetes Project
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The Community of North Lawndale
The Community of South Lawndale
North Lawndale (NL) is located on the West Side of Chicago and is one of the city’s 77 community areas. The boundaries are Western Avenue (east), Cermak Road (south), Cicero Avenue (west), and the Eisenhower Expressway (north). Like many neighborhoods on Chicago’s West Side, North Lawndale grew steadily into the mid-1960s as a hub to Chicago’s industrial age. NL is a predominantly AfricanAmerican community. In 1966, the neighborhood’s poverty, industrial decline and economic segregation, prompted Martin Luther King, Jr. to pick NL as the base for the northern civil rights movement. After his assassination in 1968, large parts of the community were burned, and crime, unemployment and physical deterioration led to further flight by residents and businesses. The Lawndale community has a rich architectural and cultural history. Recently, there have been encouraging signs of revitalization, including resource centers and housing development.
South Lawndale (SL) is adjacent to NL, separated by Douglas Park. The boundaries are Western Avenue (east), Stevenson Expressway (South), Cicero Avenue (west), and Cermak Road (north). South Lawndale, also known as Little Village, has a rich history of immigrants migrating to the area for nearby industrial employment opportunities. An arching gateway on 26th Street proclaims “Bienvenidos a Little Village”, welcoming visitors to what is considered home to the largest Mexican-American population in the Midwest. SL is recognized by many for its activism, entrepreneurship, and economic growth in an area where there are close to one thousand businesses. SL/Little Village features a strong network of community organizations.
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Sinai Urban Health Institute | Lawndale Diabetes Project
Lawndale Project Data Improving outcomes in persons with type 2 diabetes and those found to be at high risk for the disease will go a long way towards reducing its public health burden and cost of care. The LDP goal was to reach 10,000 adults with type 2 diabetes or at risk for the disease. Those persons diagnosed with type 2 diabetes by a health professional were provided an action plan to help better manage their diabetes. To achieve this goal LDP employs full-time well prepared diabetes community health educators to engage community residents. They visited over 5,500 homes in Lawndale and connected with another 3,000 individual residents through health fairs, workshops and outreach. Of the 1,334 (NL) and 831 (SL) people interviewed there was a type 2 diabetes prevalence of 25% for NL and 21% for SL. The average age in NL (50y) was higher than SL (41y). The proportion of people under the age of 40y surveyed in SL was greater than that of NL, and twice the proportion of
people over 60y was surveyed in NL compared to SL. There continues to be a very wide gap in the proportion of women surveyed compared to men in SL where there were 3 times as many women surveyed. Although the gap was not as wide, there were also more women than men surveyed in NL. The proportion of persons with a family history of diabetes was 60% in NL and slightly higher at 67% in SL. Smoking, one of the most important risk factors for bad diabetes outcomes, continues to be very high for NL where the rate is more than three times the national average. We asked residents if they were having a hard time paying for necessities such as food, rent and utilities. In NL 35% of surveyed residents stated they were having a very hard time and another 42% were having somewhat of a hard time. In SL 92% of surveyed residents were having a hard time paying for basics necessities with 40% having a very hard time.
Sinai Urban Health Institute | Lawndale Diabetes Project
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Descriptive Characteristics for Lawndale Diabetes Project Participants
NORTH LAWNDALE
26% 52% 22%
AVERAGE AGE
50
18-39y
40-59y
≥ 60 y
Difficulty Paying for Necessities Very Hard 35%
42% / 58%
40%
NO FAMILY HISTORY
60%
FAMILY HISTORY
Not Hard At All 23%
Somewhat Hard 42%
Smoking Status Current 52%
Never 34%
Former 14%
SOUTH LAWNDALE
52% 38% 10%
AVERAGE AGE
39
18-39y
≥ 60 y
Difficulty Paying for Necessities
Very Hard 40%
Not Hard At All 8%
Somewhat Hard 52%
26% / 74%
33%
NO FAMILY HISTORY
67%
FAMILY HISTORY
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40-59y
Smoking Status Current 18% Former 11%
Never 71%
Sinai Urban Health Institute | Lawndale Diabetes Project
Community Outreach Data Community Outreach Data for North Lawndale
2,750
1,334
HOMES VISITED
327
INTERVIEWS COMPLETED
25%
# ADULTS W/ TYPE-II DIABETES
% W/ TYPE-II DIABETES
352
25%
# HIGH RISK
% HIGH RISK
Community Outreach Data for South Lawndale
2,814 HOMES VISITED
172
831 INTERVIEWS COMPLETED
21%
# ADULTS W/ TYPE-II DIABETES
% W/ TYPE-II DIABETES
175
21%
# HIGH RISK
% HIGH RISK
Sinai Urban Health Institute | Lawndale Diabetes Project
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The absence of insurance for anyone struggling to live with a chronic disease like type 2 diabetes can be daunting. Many chronic disease patients refuse to seek non-emergency care because they are uninsured. This can lead to more expensive care for complications associated with poor disease management. With the expansion of health insurance under the Affordable Care Act many uninsured residents in NL and SL will have access to insurance. Figure A presents the insurance status of LDP participants. In SL 58% of respondents were uninsured, 20% had public insurance and 20% had private insurance. In NL 32% were uninsured, 58% of respondents had public insurance and only 7% had private insurance.
In the US approximately 31% of US adults have BMIs under 24.9 (ideal weight), 33% have BMIs from 25 to 29.9 (overweight), 36% have BMIs between 30 to 34.9 (obese) and 6% have BMIs over 35 (extremely obese). Figure B presents the BMI proportions for each community from LDP survey. In NL 27% were at ideal weight, 30% were overweight, 20% were obese, and 23% were extremely obese. In SL 17% were at ideal weight, 45% were overweight, 23% were obese and 15% were extremely obese. Extreme obesity in NL is nearly four times the national average and in SL more than twice the national average. Figure B. Proportions of LDP Participants Categorized According to BMI (kg/m2) in North Lawndale and South Lawndale.
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Sinai Urban Health Institute | Lawndale Diabetes Project
Education level plays an important role in employment and health literacy. Figure C below shows the education level in both communities where there were a smaller proportion of high school graduates in SL than NL. Notably, more than half of those surveyed in SL had not graduated from high school, and 35% in NL had not graduated high school. Less than 5% from either community had completed college.
Figure C. Educational Level for LDP Participants North Lawndale and South Lawndale
Sinai Urban Health Institute | Lawndale Diabetes Project
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The table below presents various measures of health status and access to health services for all participants in both communities. Nearly 20% in both communities reported that their general health was excellent/very good. More than a third of NL and more than a quarter in SL reported fair/poor health, which is twice as high as the rest of the US population. The proportion of people reporting being enrolled in managed care in SL is about four
times higher than in NL. Twice as many respondents in SL received regular care at a health clinic compared with NL. More than 67% of respondents from both communities reported having a personal doctor, and over 85% from both communities reported not having difficulties obtaining medical treatment.
Health Status and Access to Health Care North Lawndale %
South Lawndale %
General Health Excellent/Very Good Good
20.5 45.1
18.8 56.0
Fair/Poor
34.4
25.2
Unable to Afford Doctor Visit in past 12 months Yes 7.0 No 93.1 Regular Source of Medical Care Personal Doctor/ General practioner Diabetic Specialist Health Clinic Hospital No Doctor/ No Insurance Other
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11.6 88.4
38.7
26.0
1.6 28.7 23.5 6.6
0.6 59.0 8.9 4.4
1.0
1.1
Personal Doctor Caring for You Yes No
67.6 32.4
75.2 24.9
Managed Care Yes No
4.4 95.6
18.5 81.5
Difficulty Getting Medical Treatment Yes No
9.5 90.5
13.6 86.4
Sinai Urban Health Institute | Lawndale Diabetes Project
Below is descriptive data that characterizes all persons who reported having been diagnosed with type 2 diabetes. In NL 61% tested at baseline with poorly controlled HbA1c and 53% were poorly controlled in SL. Using the American Heart Association hypertension guidelines for persons with diabetes, 21% of NL residents were pre-hypertensive as were 18% in SL. Hypertension was also high with 57% of NL residents being hypertensive and 38% in SL with home systolic blood pressure measurements in the hypertensive range. In the aggregate, 78% within North Lawndale and 55% in South Lawndale are burdened with high blood pressure. This is more than 2 times the national prevalence for NL and 1.5 times the national prevalence for SL.
Descriptive Characteristics for Adults w/ Type 2 Diabetes
North Lawndale
South Lawndale
39%
47%
HbA1c < 7.0 (controlled)
HbA1c < 7.0 (controlled)
61%
HbA1c > 7.0 (poorly controlled)
53%
HbA1c > 7.0 (poorly controlled)
18%
20%
Prehypertension (120 - 130 mmHg)
57%
38%
Prehypertension (120 - 130 mmHg)
Hypertension (131 mmHg or more)
Hypertension (131 mmHg or more)
Sinai Urban Health Institute | Lawndale Diabetes Project
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We measured the effectiveness of the community health educator (CHE) intervention for LDP by testing HbA1c scores at baseline and then again at follow-up. Follow-up testing usually occurred 90-120 days from the initial baseline assessment. It was during the baseline assessment that the CHE developed with the LDP participant an individualized action plan for better diabetes self-management that included among other things changes in diet, recommendations to increase physical activity, medication adherence and routine care. Over the 90-120 day period the CHE called the participant to encourage them to stick with the action plan and offered any needed resource support such as transportation, food pantry or social services. Figure A. Distribution of All T2DM Participants who were Poorly Controlled at Baseline (HbA1c > 7.0) and 3-month Follow-up Status (n=206). Average HbA1c decrease was 0.9 (clinically and statistically significant).
Figure D. Distribution of All Adults with Type-II Diabetes Poorly Controlled at Baseline (HbA1c ≥ 7.0) and 3-month follow-up status (n=206). Average HbA1c decrease was 0.9 (clinically and statistically significant)
<6.5
12%
5 6.5 – 6.9
16%
6.9 7.0 – 8.9
52%
8.9 9.0 – 9.9
13%
14%
9.9 > 10.0
35% 50%
35%
40%
30%
20%
10%
0% 10.0
24% 0%
10%
20%
30%
40%
50%
Figure B. Distribution of North Lawndale T2DM Participants who were Poorly Controlled at Baseline (HbA1c > 7.0) and 3-month Follow-up Status (n=128). Average HbA1c decrease was 0.5 (clinically and statistically significant).
Figure E. Distribution of North Lawndale with Type-II Diabetes Poorly Controlled at Baseline (HbA1c ≥ 7.0) and 3-month followup status (n=128). Average HbA1c decrease was 0.5 (clinically and statistically significant)
13%
5 6.5 – 6.9
13%
6.9 7.0 – 8.9
56%
40%
30%
13%
9.9 > 10.0
30% 50%
33%
8.9 9.0 – 9.9
13%
60%
<6.5
20%
10%
0%
10.0
27% 0%
10%
20%
30%
40%
50%
60%
Figure C. Distribution of South Lawndale T2DM Participants who were Poorly Controlled at Baseline (HbA1c > 7.0) and 3-month Follow-up Status (n=78). Average HbA1c decrease was 1.6 (clinically and statistically significant).
Figure F. Distribution of South Lawndale with Type-II Diabetes Poorly Controlled at Baseline HbA1c ≥ 7.0) and 3-month followup status (n=78). Average HbA1c decrease was 1.6 (clinically and statistically significant)
<6.5 5 6.5 – 6.9
19%
6.9
7.0 – 8.9
45%
14%
9.9 > 10.0
44% 50%
40%
8.9 9.0 – 9.9
12%
12
9%
40%
30%
20%
10%
0%
10.0
18% 0%
10%
20%
30%
40%
50%
Sinai Urban Health Institute | Lawndale Diabetes Project
In order to examine clinically significant changes in HbA1c scores, persons were categorized into three groups based on changes between baseline and follow-up. An individual ‘improved’ if his or her HbA1c score decreased by 0.5, ‘worsened’ if the score increased by 0.5, or ‘stayed the same’ if the difference was anything in between (0.5 is the amount the literature has found to be clinically significant). The literature indicates that it can be more difficult for persons that are uncontrolled (that is, whose HbA1c is greater than 7) to lower their HbA1c levels but they are obviously the more important group to help. For Figure D (n=206) on page 12 we see an increase of 28% in participants with controlled HbA1c scores compared to baseline. Looking at Figures E (n=128) and F (n=78), respectively, we see that in NL the positive change of persons with HbA1c scores below 7.0 was 26% and was in SL 28%. Perhaps the most dramatic
interval of these graphs is for those whose scores were above 10 at baseline for it is within this group that kidney failure, blindness and limb loss will predominantly take place. Here we see clinically and significant gains. For both groups combined (Figure D) there was a decrease (improvement) of 11%. This was bigger for SL (26%) and smaller for NL (3%). These improvements are impressive and suggest that the LDP is making progress in locating people with diabetes and helping them improve their health. Of course, we look forward to bigger and more impressive improvements in the future but we are pleased with this as a beginning.
Depression is a concern for communities where hardship and managing health intertwine. There appears to be a bi-directional relationship between type 2 diabetes and depression. Many residents in NL and SL have reported weight gain because of emotional eating and depression, while others share that their struggles with diabetes and related complications make them feel down. Of all respondents at baseline, more than a quarter in NL and nearly 14% in SL were scored as being depressed on the CESD- 10, a commonly used depression index. Compared to the national depression prevalence of 6.7%, the prevalence in NL is nearly four times greater and SL is double the national average. In both communities, more than 30% of the respondents with diabetes were depressed at baseline. Depression afflicts between 20-25% adults with diabetes in the US. Residents with diabetes in North and South Lawndale, in contrast to the US population, report higher proportions of depression. The LDP CHE offers recommendations to seek mental health counseling for all participants that score high on the CESD10 or that readily share they would like to talk to mental health professional.
25%
Depression CESD-10 Score > 10 - All respondants
34%
Depression CESD-10 Score > 10 - Persons with Type - II Diabetes
14%
Depression CESD-10 Score > 10 - All respondants
30%
Depression CESD-10 Score > 10 - Persons with Type - II Diabetes
Sinai Urban Health Institute | Lawndale Diabetes Project
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PLACE AHEAD OF LETTERS
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Sinai Urban Health Institute | Lawndale Diabetes Project
Community Voices: Letters
I call this client Rose because she reminds me of a rose. When I first met her she was like a rose that was not thriving due to lack of water and nutrition. We tested her A1C and it was a 12.0. I showed her the A1C chart to let her see how her sugar level was running every day and where she was putting her health at risk. I did this intentionally because she was not testing her sugar like she should and she was shocked to learn how high her sugar was. She admitted that she did not know what to do to lower her A1C, and she didn’t know what to eat or how much to eat. She was totally unaware that exercise would help in lowering her sugar level. I made her an action plan and it was comprised of the following five steps: (1) To watch her carbohydrate intake, and watch her portion sizes; (2) Eat more vegetables; (3) Stay away from fried food to do more baking and broiling of her meats; (4) Stay away from sugary drinks, and drink only diet; (5) To exercise and take medication every day and; (6) Test her sugar every day. I encouraged her at that time to join our Diabetes Learning Circle Classes so she could learn what foods are carbohydrates and learn how to read food labels. She agreed to attend the class. The classes are twelve weeks in duration and she never missed a class. She was given a pedometer at the beginning of the class to monitor her steps and a glucose meter to test her sugars daily. I called her every week to check in with her to see if she was following her action plan and to discuss some of the things she learned in class. After three months it was time to test her A1C again. At the end of class her A1C went from 12.0 to 8.0. Her attitude had changed completely from the first time I met her. She became more outgoing and more in tune with her diabetes and she lost weight as well. Over time her skin began to clear as she started to blossom into a beautiful rose. She knows that she still have more work to do to bring the A1C down to where it should be, but I feel that now she has the knowledge to achieve success in lowering her A1C. At the end of class we usually reward the person whose A1C dropped the most by giving them a basket of goodies that they can use to take care of themselves, like nice lotions, bath oils, and other care products. We encourage them as they go on from the class to take good care of themselves. When it was announced that she won the basket she was very surprised and started crying. She is truly now in full bloom and my rose is thriving in her new environment of knowledge and understanding of type 2 diabetes. - Diabetes Block Captain, M. Shepard
Sinai Urban Health Institute | Lawndale Diabetes Project
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Conclusion
Over the past two years we have come to recognize many people who live in NL and SL, the communities surrounding Sinai Health System, tended to not be generally connected to the health care system, especially when it came to their diabetes care. Many participants had limited contact with routine clinical care and frequently sought emergency services, leaving preventive and continuing care lacking. The Lawndale Diabetes project helps to link neighbors with informal education, social services and coordinated clinical care to improve health outcomes. Community members themselves play an important role in spreading the message of the dangers of poorly controlled diabetes. We have heard countless
reports of conversations that have taken place over kitchen tables that ultimately provided our navigators with the insights necessary to provide tailored interventions to community members. With growing community partnerships and a strengthened commitment by Sinai Health System to work together internally and outside in surrounding neighborhoods the fight against diabetes looks very promising.
The Lawndale Diabetes Project would like to acknowledge and thank all of our community partners that have supported outreach and better health in Lawndale. North Lawndale
South Lawndale
Sinai Community Institute Sinai Childrenâ&#x20AC;&#x2122;s Hospital Leamington Foods Douglas Apartments Clair House Lawndale Terrace Chicago Area Project Safe Heaven Harmony Baptist Church Greater Progressive Deliverance Temple Christian Love MB Church Kingsword International Church Taste of United Baptist Central Memorial MB Church Greater Open Door Church New Progressive St. James Missionary Baptist Church Greater Rock MB Greater Galilee Baptist Church Ice Theatres Homan Square Holsten Human Capital Development Doors of Opportunity Carole Robinson Center The North Lawndale Employment Center Lawndale Christian Health Center
Little Village Lawndale High School Telpochcalli Community School Farragutt High School Eli Whitney Elementary School Saucedo Elementary School Rosario Casellanos Elementary School Fco. I. Madero Elementary School Mc Cormick Elementary School Gary Elementay School J.O. Dominguez Elementary School New life Church Puerta del cielo Church Amor de Dios United Enlace Community Jardens Little Village Elementay School
Others The Greater Humboldt Park Diabetes Empowerment Center Chicago Department of Public Health Bayer Pharmaceuticals Walgreens
Published January 2014 Data current through November 2013