The 130th Annual Meeting of APHA

Abstract #45163

Amy M. Carroll, MPH¹, Sarah E. Samuels, DrPH¹, Natalie Gutierrez², and Barbara Graves³. (1) Samuels & Associates, 1204 Preservation Park Way, Oakland, CA 94612, (510) 271-6799, amy@samuelsandassociates.com, (2) Redwood Community Health Coalition, 1180 Fourth Street, Santa Rosa, CA 95404, (3) Prevention and Planning Division, Sonoma County Department of Public Health, 1030 Center Drive #C, Santa Rosa, CA 95403

PURPOSE: The California Endowment and the County Medical Services Program of the California Department of Health Services have jointly funded Project Next Steps for two years to decrease cultural disparities and enhance client care coordination and outreach services for the prevention, diagnosis and treatment of low-income, ethnic minority patients at-risk for hypertension and diabetes. This is achieved by providing collaborative health care teams at 8 health centers throughout Sonoma County, which include a Medical Director, Public Health Nurse, and Community Health Outreach Worker. These teams work together to identify, refer, and increase the level of knowledge and motivation in newly diagnosed patients to maintain preventive health practices and disease self-management. METHODS: The goal of the evaluation is to document the implementation and measure the impact of the health care team and enhanced patient counseling approach through: 1) qualitative and quantitative health care team and community stakeholder interviews; 2) community asset/needs profiling; 3) community outreach activity tracking; 4) patient behavior and health status data collected from patient chart review and 6 enhanced counseling sessions; and 5) patient perspectives and experiences with Next Steps collected through exit surveys. FINDINGS: Preliminary data demonstrates early successes in moving patients along from one stage of behavior change to the next around weight loss, nutrition, physical activity, and smoking cessation. Results from the first year evaluation will be shared in order to highlight challenges and success around program intervention implementation, community outreach, and patient outcomes. Implications for program replication and recommendations for policy change will be discussed.

Learning Objectives:

• Understand the importance of developing new collaborative health service delivery models to overcome the barriers faced by low-income and ethnic minority individuals at-risk for chronic diseases such as diabetes and hypertension.
• Discuss the different qualitative and quantitative evaluation methods employed to capture the experience and impact of this program at eight health centers with unique health care systems, community assets/needs, and target populations served.
• Identify the program challenges and barriers faced, as well as the successful solutions employed by each of the eight Community Health Centers and by the overall Project Next Steps.

Keywords: Community Health Promoters, Chronic Diseases

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.