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Tackling Risks Associated with Diabetes Using a Population Health Driver Diagram

Related Categories: Quality Improvement

Topic: Performance Management and Quality Improvement, PHF News

Date: 4/30/2015

The Public Health Foundation (PHF), with support from the Robert Wood Johnson Foundation (RWJF), is developing and using a population health driver diagram framework to address prevention, control, treatment, and reduction of severe complications associated with diabetes. PHF has been testing an innovative approach to addressing community health challenges focusing on collaboration and alignment between public health, health care, and community organizations. Grounded in the belief that public health, health care, and community stakeholders, are more effective when they combine their efforts to address an issue than when they work separately, this approach will be used to tackle a growing challenge at the crossroads of these two sectors: improved prevention, diagnosis, and management of diabetes.

Working in three Texas regions, the Diabetes Population Health Driver Diagram Project will strive to improve the health of these communities, achieve greater health equity within the communities, and improve the value of community health investments. According to Tom Schlenker, MD, MPH, Director of Health for the San Antonio Metropolitan Health District, Texas has a high prevalence of diabetes, and an especially high incidence of diabetic complications such as amputations and renal failure. The statewide, age-adjusted diagnosed diabetic rate of 10.3/1000 has approximately doubled since the early 1990’s. In 2011, the cost of addressing diabetes in Texas was $18.5 billion, with $7.4 billion of that dedicated to public assistance, including Medicaid. With better prevention, diagnosis and management of diabetes, health care costs can be reduced and health can be improved in each Medicaid waiver region. Using a population health driver diagram to align efforts of community stakeholders around addressing diabetes may positively impact how these communities are able to use their Medicaid waivers.

Currently, PHF is working with the three Texas regions to develop and refine a Diabetes Population Health Driver Diagram. After the population health driver diagram is refined, it will be used by each region as a framework for conversations with community stakeholders about how they can collaborate to reduce risks associated with diabetes in their communities. Working together, community stakeholders will develop new or refine existing aligned interventions, measures, and targets to reduce risks associated with diabetes. Then, each group will then collaboratively implement the interventions and monitor progress. Throughout the project, PHF will provide technical assistance and training to the Texas regions, including quality improvement strategies that will be used to help develop, implement, track progress of, and improve interventions to help achieve measureable results.

Since 2013, PHF has successfully used the population health driver diagram framework in communities to help achieve health objectives at the crossroads of public health and health care. In 2014, PHF led development of the Population Health Driver Diagram to Increase Use of Oral Health Care to help public health and health care work collaboratively to improve the use of oral health care in communities.

Feedback on use of these completed population health driver diagrams has been extremely positive, which has led to PHF’s commitment to expand this approach for use in other communities. The population health driver diagram framework holds great promise for helping to align efforts within communities that can lead to community-wide measurable and sustainable improvements in population health.
PHF has created a tool to help develop population health driver diagrams and is currently seeking sponsors to help test and further refine these driver diagrams for potential use in communities.


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Tackling Risks Associated with Diabetes Using a Population Health Driver Diagram