Population-wide Approaches to Prevent Obesity, Diabetes and Heart Disease

The Problem:
The SC Department of Health and Environmental Control Midlands Regional Office noticed the need for prevention efforts involving obesity, diabetes, heart disease, stroke and reducing health disparities among adults within the counties of Chester, Fairfield, Kershaw and Richland.

The Goal:
To effectively use the Prevention and Health Across Systems and Environments (PHASE) grant to support the implementation of population-wide and priority population approaches to prevent obesity, diabetes, and heart disease and stroke and reduce health disparities among adults.

Method & Implementation:
DHEC assisted John A. Martin Primary Health Care Center and Fairfield Medical Associates with creating a monitoring system and registry for their patients with hypertension and diabetes to help identify patients needs more effectively. This data allowed the facility to provide better and earlier interventions to improve health outcomes. In addition, the American Health Association Check Change Control Program was implemented at Fairfield Medical Associates to increase the use of self-measured blood pressure monitoring combined with clinical support for patients with uncontrolled hypertension.

John A. Martin Primary Health Care Center was also able to include the hypertension registry and prediabetic registry in their electronic health record system. Policies were created at both the Center and Fairfield Medical Associates to increase the engagement of non-physician team members in hypertension management in community health programs. Individuals from the counties were provided free one on one home visits to educate them on how to take their blood pressure correctly, medication reconciliation and health education.

Results:
While the work is ongoing, DHEC had established over 15 sites of the SC PHASE community partnerships within the Midlands Region.