Alabama Hospital Develops Community Program to Decrease Health Disparities

Baptist Medical Center South, a 492-bed hospital in Montgomery, Alabama, is addressing health disparities in their communities. Their focus is on uncontrolled diabetes in younger African-American patients, and the priority population is African-American patients under the age of 55 years and with an A1c of 7 or greater.

Short-term goals include: 1) Provide patient and family education on budget-friendly nutrition, know your numbers, medication management, and living with diabetes; and 2) Address barriers to care by offering wellness checks closer to home, incorporating focus on priority population into Community Connection and outreach visits with churches and community organizations throughout the service area.

Long-term goals include: 1) Develop an engaging community program for African-American patients with A1c 7 or greater, incorporating quarterly health checks, nutrition and fitness education, virtual peer-group sessions, and incentives.

Action Steps Underway:

1. Staff education on diabetes care and resources added to the nurse residency program and patient care technician training curriculum
2. Community Connection events with partner churches and community centers

• Assistance provided for establishing PCP relationships for elevated stats
• Year-over-year change for two sites visited in Q1 of both years: 182 (2023); 124 (2024)

3. Social Determinants of Health (SDOH) pilot in PCP office
4. Promotion of The Center for Wellbeing’s Pre-Diabetes Classes
5. Abridged Diabetes Education Booklet, available with QR code

To date, there is a decrease in the A1c values for African-American patients under the age of 55 years in CY2023 compared to CY2022. See the table below.

Future Plans:

1. Heat map of AICs for focused community engagement
2. Adding diabetes information to patient TV channel
3. Extend staff education on diabetes care and resources to our virtual care nursing partners
4. Consideration for a virtual platform for diabetes classes
5. Improved partnership with food bank for vouchers (e.g., diabetes meal boxes in key locations)
6. Additional team members from primary care staff