Funding and Educational Opportunities

The Idaho Diabetes, Heart Disease, and Stroke Prevention (DHDSP) Program periodically provides funding opportunities and highlights educational opportunities for providers and partners interested in preventing and managing chronic diseases.

Funding Opportunity – Now OPEN!

The Idaho DHDSP Program is currently seeking applications from Idaho healthcare organizations that provide outpatient primary care for adults (18 – 85) to implement analytic and evidence-based interventions to improve diabetes and heart disease prevention and management practices in clinical settings. Applications are due electronically by 5:00 pm MT on Friday August 6, 2021 (email completed applications to Mara Stauss, mara.stauss@dhw.idaho.gov). Please review the entirety of the application package: 

The Idaho DHDSP Program plans to fund at least two (2) health systems this year at a maximum of $30,000 per health system (through June 29, 2022). Successful projects may be extended and receive an additional one (1) year of funding.

The current pandemic has further reinforced the need to prevent and properly manage chronic disease. Diabetes and cardiovascular disease remain leading causes of death and disability in Idaho and contribute significantly to the nation’s $3.8 trillion in annual health care costs. An estimated 10.3%, or about 137,000, of Idahoans, has diabetes, with prevalence rates increasing steadily for the past 20 years. Nearly one in three Idaho adults has hypertension (30.6%) or high cholesterol (28.8%). In 2019, cardiovascular disease was the leading cause of death in Idaho (21.2% of deaths), with diabetes ranked seventh at 2.9% of deaths.

The DHDSP Program is housed within the Bureau of Community and Environmental Health (BCEH), Division of Public Health, at the Idaho Department of Health and Welfare. In 2018, Idaho DHDSP Program was awarded a five-year grant (2018-2023) by the Centers for Disease Control and Prevention (CDC) “Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke” (CDC-RFA-DP18-1815, CFDA# 93.426).

The purpose of the grant is to work with health systems and stakeholders to support the implementation and sustainability of analytic and evidence-based interventions to identify, prevent, and manage prediabetes, diabetes, high blood pressure, and high blood cholesterol and increase community-clinical linkages that support systematic referrals, self-management, and lifestyle change for individuals with prediabetes, diabetes, high blood pressure, and high blood cholesterol.

As a benefit, the DHDSP Program provides full access to an experienced, clinical quality improvement contractor to support clinic initiatives, develop workplans, and engage clinical teams.  Funded healthcare organizations also receive a baseline assessment, Electronic Health Record (EHR) data validation on select measures, access to data visualizations, and the ability to adapt implementation strategies to meet the needs of their clinic and patient population.

Questions or want to learn more?
Mara Stauss
Health Program Specialist

Evidence informed practices Category A: Prediabetes & Diabetes

Workplan guidance

The purpose of this guidance document is to provide health systems the Foundational Activities and/or Strategy options to select from to develop an annual work plan. The workplan will then be implemented during the subgrant performance period to improve outcomes related to diabetes and prediabetes. 

Health Systems must select at least one Strategy from Category A to focus on during the subgrant year.  For each topic chosen, Foundational Activities, include the Deliverables, must be completed along with, or prior to, at least one Strategy (see DHDSP Health System Framework shown below).
 

Diabetes Foundational Activities Strategy 1: Refer patients to DSMES Programs
Diabetes Foundational Activities Strategy 2A: Establish a DSMES Program
Diabetes Foundational Activities Strategy 2B: Expand/Enhance your DSMES Program
Diabetes Foundational Activities Strategy 3: Engage Pharmacists in MTM

 

Prediabetes Foundational Activities Strategy 1: Refer Patients to National DPPs
Prediabetes Foundational Activities Strategy 2A: Establish a National DPP
Prediabetes Foundational Activities Strategy 2B: Expand your National DPP

 

Category A: Diabetes Foundational Activities
Key Activities Deliverables
1.    Implement workflows/CDSS to ensure completion of A1c testing among diabetic patients  Policy and workflow for diabetic patients following national guidelines (attached to Subgrant Monitoring Report (SMR))
2.    Develop and maintain accurate EHR reports/registries
-    Patients diagnosed with diabetes
-    Patients without recent A1c test
-    Patients with uncontrolled diabetes (NQF 59)
-    Patients referred to DSMES
-    Patients enrolled in DSMES
Reported metrics through SMR/provided to OHI
3. Disseminate reports and data to staff on routine basis SMR

 

Diabetes Strategy 1: Increase referrals of diabetic patients to an accredited/recognized DSMES program in your community
Outcome Measure
Decreased proportion of people with diabetes with an A1C > 9 (NQF 0059)

 

Performance Measures
Increased # of referrals for people with diabetes to a DSMES/T program
# of patients with diabetes within the health system with at least one encounter at an ADA-recognized/ADCES-accredited DSMES program.

 

Key Activities Deliverables
1. Identify and develop referral partnerships with accredited/recognized DSMES programs List of DSMES programs referring to (attached to SMR)
2. Implementing a DSMES Referral Policy/Workflow, including tracking follow-up/participation Referral Policy/Workflow (attached to SMR)
3.    *Negotiated with Department based on needs of health system - Key Activities 1 and 2 must be satisfied.  *TBD

 

Diabetes Strategy 2A: Establish an accredited/recognized DSMES program within your organization
Outcome Measure
Decreased proportion of people with diabetes with an A1C > 9 (NQF 0059)

 

Performance Measures
# of new ADA-recognized/ADCES-accredited DSMES programs established
# of new ADA-recognized/ ADCES -accredited DSMES sites established
Key Activities  Deliverables
1.    Develop a program that follows the 10 standards of DSMES and apply to become an accredited/recognized DSMES program Accreditation received for DSMES program from accrediting body (SMR attachment)
2.    Document and implement/optimize referral process workflow for internal/external providers Written workflow (SMR attachment) 
Diabetes Strategy 2B: Expand and/or enhance an existing accredited/recognized DSMES program within your organization
Outcome Measure
Decreased proportion of people with diabetes with an A1C > 9 (NQF 0059)

 

Performance Measures
# of new ADA-recognized/ ADCES -accredited DSMES sites established
# of people with diabetes referred to a DSMES program
# of people with diabetes with at least one encounter at an ADA-recognized/ ADCES -accredited DSMES program

 

Key Activities  Deliverable
1.    Implement Marketing and Communication Plan Copy of Plan (SMR attachment)
*Negotiated with Department based on needs of health system – see Example Activities - Key Activities 1 must be satisfied  
Example Activities
·    Establish new ADA-recognized/ADCES-accredited DSMES sites
·    Expand to virtual DSMES 
·    Develop partnerships to accept referrals from external agencies  
·    Document and optimize systematic referral pathway, including integration with EHR
·    Build EHR capability to support bidirectional communication and documentation for referral follow-up and participant progress 
·    Set up billing for DSMES, including Medicaid reimbursement (ADA recognition and services delivered by a CDE required)
·    Integrate DSMES into coordinated care (e.g., Patient-Centered Medical Homes) 
·    Identify and eliminate barriers to access to increase participation in DSMES services (important to understand these barriers before undertaking marketing efforts). 
·    Engage Community Health Workers to link people with diabetes to DSMES services 

 

Diabetes Strategy 3: Engage Pharmacists in Medication Therapy Management (MTM) for patients with diabetes
Outcome Measure
Decreased proportion of people with diabetes with an A1C > 9 (NQF 0059)

 

Performance Measures
Number of pharmacists using patient care processes to promote medication management for people with diabetes

 

Key Activities  Deliverables
1.    Document and optimize referral pathway with pharmacists, including defining criteria for diabetic patients who would benefit from working with pharmacists on MTM Referral Protocol/Pathway (SMR Attachment)
2.    Develop/update patient care processes to include medication therapy management for people with diabetes Documented patient care processes for MTM
3.    Negotiated with the Department based on needs of health system* Key Activities 1 & 2 must be satisfied *TBD

 

 

Category A: Prediabetes Foundational Activities
Key Activities Deliverables
1.    Develop workflow to screen, test, and diagnose patients for prediabetes Written workflow
2.    Develop and maintain accurate EHR reports/registries
-    Patients diagnosed with prediabetes 
-    Patients referred to National DPP 
-    Patients enrolled in National DPP
Subgrant Monitoring Report (SMR) 
3.    Disseminate reports and data to staff on routine basis SMR

 

Prediabetes Strategy 1: Increase referrals of patients with prediabetes to CDC-recognized National DPP in your community
Outcome Measures
Increased # of people with prediabetes identified within the health systems

 

Performance Measures
Increased # of people with prediabetes referred from health systems to the National DPP
# of participants enrolled in the National DPP programs

 

Key Activities  Deliverables
1.    Identify and develop referral partnerships with CDC-recognized National DPPs List of National DPPs referring to (SMR) 
2.    Document and implement/optimize Referral Policy/Workflow, with CDC-recognized National DPPs, including follow-up/participation  Referral Policy/Workflow (SMR Attachment) 
3.    Increase patient and health care provider awareness of prediabetes as a serious health condition and the National DPP Communication Plan (SMR Attachment) 
4.    Negotiated with the Department based on needs of health system*  *TBD

 

Prediabetes Strategy 2A: Establish a CDC-recognized National DPP within your organization
Outcome Measures
Increased # of patients enrolled in the National DPP

 

Performance Measures
# of new CDC-recognized/pending recognition National DPPs established
# of people with prediabetes referred to the National DPP

 

Key Activities  Deliverables
1.    Develop a program that follows the CDC standards and apply to become a CDC-recognized National DPP Copy of application
2.    Document and optimize referral pathway, including integration with EHR, and track referral follow-up/patient progress (internal and external) Referral and follow-up workflow
3.    Train at least 2 lifestyle coaches and hold a National DPP cohort SMR 

 

Prediabetes Strategy 2B: Expand a CDC-recognized National DPP within your organization
Outcome Measures
Increased # of patients enrolled in the National DPP

 

Performance Measures
# of participants referred to the National DPP

 

Key Activities  Deliverables
1.    *Negotiated with Department based on needs of health system *TBD

 

Example Activities
·    Expand to virtual NDPP
·    Promote the National DPP (required Deliverable = Marketing and Communication Plan)
·    Develop partnerships to accept referrals from external agencies  
·    Build EHR capability to support bidirectional communication and documentation for referral follow-up and participant progress 
·    Set up billing for NDPP 
·    Increase health care providers awareness of prediabetes as a serious health condition and the National DPP
·    Utilize Value-Based Payment for populations unable to participate in the National DPP based on ability to pay (additional conditions apply; please contact the Department)

 

Evidence informed practices Category B: Hypertension & High-Blood Cholesterol

Workplan guidance

The purpose of this guidance document is to provide health systems the Foundational Activities and/or Strategy options to select from to develop an annual work plan. The workplan will then be implemented during the subgrant performance period to improve outcomes related to hypertension and cholesterol control. 

Health Systems must select at least one Strategy from Category B to focus on during the subgrant year. For each Strategy chosen, Foundational Activities must be completed along with, or prior to, at least one Strategy (see DHDSP Health System Framework shown below).

Hypertension Foundational Activities Strategy 1: Refer Patients to Community Programs/Resources
Hypertension Foundational Activities Strategy 2: Identify and Address Disparities
Hypertension Foundational Activities Strategy 3: Engage Pharmacists in MTM

 

High Blood Cholesterol Foundational Activities Strategy 1: Refer Patients to Community Programs/Resources
High Blood Cholesterol Foundational Activities Strategy 2: Identify and Address Disparities
High Blood Cholesterol Foundational Activities Strategy 3: Engage Pharmacists in MTM

 

Category B: Hypertension Control & Undiagnosed Hypertension Foundational Activities
Key Activities Deliverables
1.    Develop and maintain accurate EHR reports/registries
-    Patients with undiagnosed hypertension
-    Patients diagnosed with hypertension
-    Hypertensive patients with controlled blood pressure (NQF 18)
-    Hypertensive patients with uncontrolled blood pressure
 
Subgrant Monitoring Report (SMR)
2.    Disseminate reports and data to staff on routine basis SMR
3.    Ensure accurate blood pressure measurement is occurring Training method and number trained
4.    Follow 2017 national guidelines, including standardized 10-year risk assessment for patients indicated Hypertension Policy/Care Guidelines (attached to SMR) Including a Team-Based Care policy.

 

Hypertension Control & Undiagnosed Hypertension Strategy 1: Refer patients to evidenced-based, CDC-recognized community programs/resources
Outcome Measure
Proportion of adults with known high blood pressure who have achieved blood pressure control (NQF 0018)

 

Performance Measures
# of patients with high blood pressure referred to an evidence-based lifestyle program

 

Key Activities Deliverable
1.    Document and implement/optimize referral workflow Workflow (SMR attachment)
2.    Identify and develop referral partnerships with CDC-Recognized programs (see Note) List of programs that patients are being referred to

 

Example Activities  Deliverable
Blood Pressure Monitor Loaner Program (approval and negotiation with the Department require; subgrant funds cannot be used to purchase BP monitors; however, if the sub-recipient health system can acquire monitors through another funding source, subgrant funds can be used to support program implementation) *TBD

 

Note: Programs that qualify as CDC-recognized community programs/resources include: 
Taking Off Pounds Sensibly (TOPS), Curves Complete, Weight Watchers (WW), Supplemental Nutrition and Assistance Program and Education (SNAP-ED), Expanded Food and Nutrition Education Program (EFNEP) and the National Diabetes Prevention Program (if hypertension can be tracked). For a list of programs in your service area, please contact Mara Stauss, Health Program Specialist at Mara.Stauss@dhw.idaho.gov

Hypertension Control & Undiagnosed Hypertension Strategy 2: Identify and Address Disparities
Outcome Measure
Proportion of adults with known high blood pressure who have achieved blood pressure control (NQF 0018)

 

Performance Measures
# of clinics or health care system sites that use standardized clinical quality measures to track differences in blood pressure control in priority populations compared to overall populations

 

Key Activities  Deliverables 
1.    Build capacity to run reports for patients diagnosed with hypertension broken out by other measures to identify disparities e.g. insurance type, race/ethnicity, age, # of medications, comorbidities, tobacco users, etc. at the clinic and/or provider level. List which disparities exist in the SMR and NQF 0018 on disparate populations identified
2.    Develop plan addressing the disparities identified. Written plan to address disparities identified.

 

Hypertension Control & Undiagnosed Hypertension Strategy 3: Engage pharmacists in Medication Therapy Management (MTM)
Outcome Measure
Proportion of adults with known high blood pressure who have achieved blood pressure control (NQF 0018)

 

Performance Measures
# of pharmacists who provide MTM services to promote medication self-management and lifestyle modification for patients with high blood pressure

 

Key Activities  Deliverables
1.    Document and optimize referral pathway with pharmacists, including defining criteria for hypertensive patients who would benefit from working with pharmacists on MTM Referral Protocol/Pathway (SMR Attachment)
2.    Develop/update written patient care processes to include medication therapy management for patients diagnosed with hypertension Documented patient care processes for MTM
3.    Negotiated with the Department based on needs of health system* Key Activities 1 & 2 must be satisfied *TBD

 

Category B: Cholesterol Foundational Activities - CMS 347v3
Key Activities Deliverables
1.    Develop and maintain accurate EHR reports/registries
-    Statin therapy for the prevention and treatment of cardiovascular disease (CMS 347)
Subgrant Monitoring Report (SMR, due quarterly
2.    Disseminate reports and data to staff on routine basis SMR
3.    Ensure patients have recent LDL-C results documented  SMR
4.    Follow 2018 national guidelines, including standardized 10-year risk assessment for patients indicated High-Blood Cholesterol Policy/Care Guidelines (attached to SMR) Including a Team Based Care policy

 

Cholesterol Control Strategy 1: Refer patients to evidenced-based, CDC-recognized community programs/resources
Outcome Measure
Proportion of patients considered at high risk of cardiovascular events who have their cholesterol managed with statin therapy (CMS 347v.3)

 

Performance Measures
# of patients with high blood cholesterol referred to an evidence-based lifestyle program

 

Key Activities Deliverable
1.    Document and implement/optimize referral workflow Workflow (SMR attachment)
2.    Identify and develop referral partnerships with CDC-Recognized programs (see Note)  List of programs that patients are being referred to

 

Note: Programs that qualify as CDC-recognized community programs/resources include: 
Taking Off Pounds Sensibly (TOPS), Curves Complete, Weight Watchers (WW), Supplemental Nutrition and Assistance Program and Education (SNAP-ED), Expanded Food and Nutrition Education Program (EFNEP) and the National Diabetes Prevention Program (if high-blood cholesterol can be tracked). For a list of CDC-recognized programs in your service area, please contact Mara Stauss, Health Program Specialist at Mara.Stauss@dhw.idaho.gov
 

 

Cholesterol Control Strategy 2: Identify and Address Disparities
Outcome Measure
Proportion of patients considered at high risk of cardiovascular events who have their cholesterol managed with statin therapy (CMS 347v.3)

 

Performance Measures
# clinics or health care system sites that use standardized clinical quality measures to track differences in cholesterol management in priority populations compared to overall populations

 

Key Activities  Deliverables 
1.    Build capacity to run reports for patients diagnosed with high cholesterol broken out by other measures to identify disparities e.g. insurance type, race/ethnicity, age, # of medications, comorbidities, tobacco users, etc. at the clinic and/or provider level. List which disparities exist in the SMR and NQF 0018 on disparate populations identified
2.    Develop plan addressing the disparities identified. Written plan to address disparities identified.

 

Cholesterol Control Strategy 3: Engage pharmacists in Medication Therapy Management (MTM)
Outcome Measure
Proportion of patients considered at high risk of cardiovascular events who have their cholesterol managed with statin therapy (CMS 347v.3)

 

Performance Measures
# of pharmacists who provide MTM services to promote medication self-management and lifestyle modification for patients with high blood cholesterol

 

Key Activities  Deliverables
1.    Document and optimize referral pathway with pharmacists, including defining criteria for patients with high cholesterol who would benefit from working with pharmacists on MTM Referral Protocol/Pathway (SMR Attachment)
2.    Develop/update written patient care processes to include medication therapy management for patients diagnosed with high cholesterol Documented patient care processes for MTM
3.    Negotiated with the Department based on needs of health system* Key Activities 1 & 2 must be satisfied *TBD

 

"[The subgrant] has enabled us to create and develop our Chronic Care Management program. It has been so rewarding to see the excitement in my patients when they get a lower A1C result, BP improvement, and weight loss."
Partner organization
Educational opportunities

Start a National Diabetes Prevention Program in your community! 

  • Lifestyle coach 3-day virtual training on July 20, 27, August 3, 2021
  • Email Dorothy Plaza dorothyrplaza@gmail.com to learn more and register.

Integrating Oral Health into Medical Practice

The Healthy Me is Cavity-Free Initiative within the Idaho Oral Health Alliance is proud to offer this course as the first in a series of courses, which will educate health care providers on the basics of integrating oral health into their everyday practices and protocols. Increasing your knowledge about the relationship between oral health and overall health will benefit you and the health outcomes of your patients!

  • August 10, 2021, 12 - 1 pm MST
  • Email Katrina Hoff khoff@jannus.org to learn more.
Order free healthcare materials

Order or download free multilingual materials to help others learn about diabetes, heart disease, stroke, blood pressure, and developing healthy habits. You'll find brochures, care cards, posters, and educational items for ordering.