IUMG and YMCA Work to Prevent Type 2 Diabetes
Indiana University Medical Group (IUMG) and Indiana University (IU) has successfully built a program to identify and assist patients at risk for developing type 2 diabetes. This initiative includes a partnership between the YMCA of Greater Indianapolis and several IUMG practice sites to provide formal lifestyle weight management programs to prevent the development of diabetes in adult patients with pre-diabetes.
In this collaboration, public health researchers at IU helped to develop and foster a relationship between IUMG and the YMCA to address the epidemic of obesity and a rapid increase in new cases of type 2 diabetes. Collaborators turned to the Diabetes Prevention Program (DPP) – a large clinical research study funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) – as a model for the best evidence for successful diabetes prevention. The DPP demonstrated the benefit of two interventions (intensive lifestyle and metformin) to prevent or delay the development of diabetes in adults with pre-diabetes.
Despite compelling evidence from the DPP that an intensive lifestyle intervention can cut the development of type 2 diabetes by more than half, few primary care clinics are able to offer the level of weight management resources offered as part of the DPP lifestyle intervention. Although these interventions might reach a broader population if offered entirely in the community, keeping a connection to primary care will ensure that these programs continue to attract persons who have completed the blood tests needed to confirm a pre-diabetes diagnosis. Also, if the partnership proves effective in preventing diabetes, it is possible that health insurers might choose to pay for diabetes prevention services for high-risk primary care patients in the future.
IU has been working with the YMCA to adapt formal guidelines for the DPP lifestyle intervention (http://www.bsc.gwu.edu/dpp) to develop a sound approach for offering the DPP in the community. This collaboration began in 2003 when IU researchers met YMCA administrators at a local community wellness interest forum and learned about the YMCA’s interest in developing programs in conjunction with local healthcare partners - particularly in the area of obesity prevention and management. Over a series of face-to-face meetings, IU worked with the YMCA and IUMG to build a partnership with a mission to deliver lifestyle intervention programs to prevent diabetes in adults. One critical “tool” for developing this relationship was the participation of a local community “liaison” - a local health plan administrator who happened to be both a physician and a member of the YMCA advisory board. This “liaison” understood the needs and spoke the language of each organization involved in the partnership.
Together, the YMCA and IU developed proposals for federal and private foundation research funding to subsidize and study different aspects of the partnership. IU and the YMCA have now completed two of these studies, and two additional studies are underway. Currently, the group is exploring how to involve YMCA professionals directly in efforts by participating primary care teams to implement pre-diabetes testing and weight management counseling at the clinics. The group hopes that this approach will generate a model for replicating similar “partnered” diabetes prevention services in varied community and practice settings across the U.S.
Research funding has allowed the YMCA and IUMG to provide the program at no cost to many of the study participants. Since free programs are difficult to maintain, the group is grappling to develop novel cost-sharing strategies to offer the program at minimal cost to participants. The YMCA, a not-for-profit organization, has a policy to turn no person away for inability to pay for a program. Many YMCA programs used by low income persons are underwritten by charitable donations from local organizations and philanthropies. Collaborators attempt to reduce costs further by using publicly available materials (i.e. National Diabetes Education Program diabetes prevention materials and DPP intervention manuals). IU researchers also aim to use the program evaluation to inform decisions by health insurers about whether to pay for aspects of these formal prevention activities in patients at particularly high risk for developing diabetes.
Dr. Ackermann, who leads the evaluation group at IU, believes that the partnership has been successful, in part, because of the involvement of a local professional working as a "boundary spanner" between the YMCA and IUMG to help from the outset to develop a common dialogue and understanding of differences in organizational perspectives. Dr. Ackermann also feels that the partnerships were successful because of “mutual respect and a strong commitment to the original mission of developing a national program model that could impact the health and well-being of millions of Americans.” This mission has guided efforts to ensure that the partnership remains sensitive to the needs and resources of both the YMCA and the clinics.
Dr. Ackerman warns that in order to be successful someone must continuously monitor progress so problems can be identified early and solved collaboratively. He explains, “In one of our studies, primary care clinics implemented strategies to identify adults with pre-diabetes. These patients were then briefly counseled at the practice and offered information about how to access the formal YMCA program free of charge. While implementing approaches at the local level, we experienced several “cycles” of new barriers to maintaining these pre-diabetes services as “routine” activities in each clinic. When these barriers pop up, the flow of patients going to the YMCA slows and there is a delay in initiating new diabetes prevention classes.” He further explains that it is during such times, that the YMCA struggles to maintain contact with these individuals and to keep them activated to use the program. Without ongoing monitoring of the entire process, such problems could continue for months and cause the partnership to wither.
Fortunately, the group views these struggles as an opportunity to strengthen their partnership by working collaboratively to find solutions to these barriers. To assist in this process it has been fruitful to have both the community partner and the practice team in the same room to troubleshoot collaboratively. IU aims to develop a model for how to develop relationships quickly and to solve problems more effectively and more collaboratively in new settings. Dr. Ackermann believes these types of problems often occur at the outset of a new partnership, when the partners are not as familiar with one another. As time passes, the group develops, with nurturing, a growing mutual trust across organizations that helps strengthen problem solving and the development of additional partnerships in new areas.