Population Health Initiative to Improve Chronic Disease Management

The Johns Hopkins Health System and the University of Maryland Medical Center have received an award of $43 million over five years to improve population health and chronic disease management for individuals with type 2 diabetes.

The Baltimore Metropolitan Diabetes Regional Partnership is a statewide initiative that will aim to increase the number of available city-based programs to prevent or delay type 2 diabetes.

The organizations will also work to broaden access to community-based diabetes management programs to help people in the Greater Baltimore region with diabetes improve their health outcomes.

“Diabetes ranks among the highest-cost conditions to our healthcare and public health systems, and is a disease of racial and socioeconomic health inequalities,” said Felicia Hill-Briggs, professor at the Johns Hopkins University School of Medicine and senior director of population health research and development for Johns Hopkins Medicine.

“This award provides unprecedented opportunity to reduce the burden of diabetes in Maryland by bringing high-quality, proven prevention and self-management training programs right to community venues where they can be accessed by those most at risk, with the infrastructure and capacity-building for these programs to remain sustainable long term.”

The Maryland Health Services Cost Review Commission (HSCRC) gave the award to the two healthcare organizations to expand the CDC’s National Diabetes Prevention Program and American Diabetes Association-recognized Diabetes Self-Management Education and Support programs, evidence-based diabetes management programs.

“We appreciate the HSCRC’s significant investment in this new partnership which will enable us to expand our community-based programs to provide patients with type 2 diabetes the tools to help them better manage their disease and to develop educational resources for prevention, which is critical to stemming this escalating public health threat,” said Anne D. Williams, DNP, MS, RN, Director of Community Health Improvement at the University of Maryland Medical System.

The awards require both Johns Hopkins and University of Maryland Medical Center to partner with community-based care delivery sites, and to offer services in non-healthcare settings. The Johns Hopkins Health System will expand the diabetes prevention program offered by the Johns Hopkins Brancati Center for the Advancement of Community Care.

“When the Brancati Center started working with our community partners in East Baltimore in 2015, we only dreamed that we would one day see diabetes prevention programs across the entire city. With this HSCRC grant, we will get there,” said Nisa Maruthur, a physician, researcher and associate professor of medicine at Johns Hopkins.

The award will help expand the Johns Hopkins Health System’s accredited diabetes management sites to include community-based clinics and pharmacies in addition to the hospital-based clinics that currently provide the service.

“We’re excited to get to work to make our city and our state healthier by increasing access to diabetes education for our patients with diabetes,” said Nestoras Mathioudakis, associate professor at the Johns Hopkins University School of Medicine and clinical director of the division of endocrinology, diabetes and metabolism.

“We know that diabetes education works to help people lower their blood sugar, blood pressure and cholesterol. Unfortunately, very few eligible patients receive evidence-based diabetes self-management training. Through this important partnership, we will work to ensure that our patients with diabetes receive the training and skills they need to feel empowered to effectively manage this chronic disease.”

The University of Maryland’s Center for Diabetes and Endocrinology (UMCDE) is an American Diabetes Association-accredited program for diabetes self-management education. UMCDE staff has successfully lowered patients’ A1C by 2.2 percent in the last year, and with the grant they expect to continue to improve their efforts.

“We look forward to partnering with Johns Hopkins on this crucial initiative, which leverages more than 10 years of collaboration between our two institutions on training and striving to improve the health of highest-risk and underserved populations with diabetes,” said Kashif M. Munir, associate professor of medicine at the University of Maryland School of Medicine, director of the UMCDE and head of the Division of Endocrinology at the UMMC Midtown Campus.

“This grant will enable us to provide access to diabetes self-management training to 25 percent more of the population with diabetes in the communities we serve and expand access to programs to prevent type 2 diabetes in 20 percent more of the population with prediabetes.”

The HSCRC grant will enable community and provider organizations to form sustainable wraparound services that will address barriers to accessing care and enhance diabetes self-care activities.

“I’ve seen multiple generations of families impacted by type 2 diabetes. This disease can be physically devastating and can lead to hospitalizations, impact quality of life and result in missed work, which can hurt families financially. We know that there are lifestyle changes and early interventions that can break these cycles and improve lives,” said Kevin Sowers, president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine

“This grant will allow us to address structural impediments to living healthy lifestyles, while empowering our community with the evidence-based information needed to address the diabetes epidemic in Baltimore. We’re happy to work alongside University of Maryland to improve the health of our community.”

The partnership will also address disparities in the prevalence of diabetes. Blacks in Maryland are more likely than whites to have the condition, and low-income earners are seven times more likely to have the disease than wealthy residents.

“Diabetes is a significant public health problem in Baltimore — one that affects many families and contributes to an array of other medical issues,” said Bert W. O’Malley Jr., president and chief executive officer of the University of Maryland Medical Center.

“As an anchor institution in West Baltimore, UMMC welcomes this opportunity to work with Johns Hopkins to improve access to diabetes care and prevention services that will improve the health and well-being of city residents — and keep them out of the hospital.”