KEY PARAMETERS

• Population targeted: Adults age 65+ with Type 2 Diabetes

• Geographic setting: Urban

• Service delivery setting: Clinical and community based

• Services offered: Medical nutrition therapy (MNT), personal health coaching that included nutrition

education in the form of personalized shopping and cooking instruction, and linkages to additional community

resources out of the clinical setting, into the patient’s home or preferredbcommunity location.

• Number of staff/FTEs dedicated to innovation project: 14 staff/total of 4.65 FTE

• Total grant funds received: $250,000

• Total project period: Two years (2017 – 2019)

• Total funding leveraged from organization (cash/in-kind): $82,304 in-kind

TAKING CHARGE OF DIABETES

PROJECT PURPOSE

• To address patient care beyond the clinical walls by offering a multi-component, home-based intervention to

improve health outcomes at the patient level and reduce health care costs at the system level for adults 65+

with Type 2 Diabetes.

PROJECT LENGTH

• Two years

PROJECT COMPONENTS

• Partnership between two hospitals (Thomas Jefferson University Hospital and Jefferson Health) and the

Health Promotion Council

• Provision of nutrition services including Medical Nutrition Therapy and nutrition education

• Provision of an evidence-based self-management intervention – Diabetes Self-Management Program (DSMP)

• Establishment of a referral network established to support diet-related programmatic supports

(i.e., Food Stamps, emergency food supplies, targeted meal delivery services aligned with dietary needs, etc.)

ORGANIZATION:

Health Promotion Council

ADMINISTRATION FOR COMMUNITY LIVING INNOVATIONS IN NUTRITION PROGRAMS AND SERVICES CAPSTONE SERIES

ABOUT US

Health Promotion Council of Southeastern Pennsylvania, Inc., a nonprofit corporation, was founded in 1981 

to implement community-based hypertension education and control programs. Known then as Southeastern 

Pennsylvania High Blood Pressure Control Program and funded by the Pennsylvania Department of Health, it 

was as part of a national hypertension control effort organized by the National Heart Blood and Lung Institute 

(NHLBI).  When NHLBI disease control efforts broadened to include cholesterol and tobacco control, HPC took 

on these additional disease prevention concerns and changed its 

name accordingly.

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Data Access and Billing

• Integrating the registered dietitian as a hospital employee and the Health Coach as a community

organization employee will allow better integration of roles while efficiently servicing the patient, the

hospital and the community.

• Consider having a robust system to access medical records and health insurance billing structure for all

partners involved in the project to facilitate referral, scheduling and loop back to medical provider.

• Understanding MNT billing system for different health insurance plans was a significant undertaking.

It is important to have the knowledge MNT billing best practices and health insurance plan implications

including reimbursement policies of all insurers to identify patients that are fully covered, have co-pays or

are not covered.

• It would be imperative to have access to medical records with future programs in order to complete medication

adherence evaluations and facilitate loop back to medical provider.

Patient Recruitment and Enrollment

• Data requests should include as many exclusion criteria as possible and driven by the capabilities of the

HIT system you are using. For example, any data within Epic that is placed in a structured data field could be

used. For example, knowing the patients’ primary language spoken, patients requiring an interpreter, diagnosis

of dementia (as well as all the variations of dementia), identification of dementia medications, and limiting

patient population to only zip codes within acceptable distance for the intervention. The primary and secondary

admission or discharge diagnoses are not helpful since they often do not reflect the full scope of why the

patient was in the hospital or emergency room (ER).

• In the age of caller identification (CID), most people do not answer their phones when they do not recognize

the number. Future considerations to address this should include having a specific phone number that

identifies the caller by contactname (for example “Jefferson”) or agency name (for example “Health Promotion

Council”). Another solution would be to utilize text messages as individuals may be more likely to read a

message before deleting.

PROJECT IMPACT

• Taking Charge has a strong potential to inform future public health practices and community-clinical

partnerships for the delivery of health care services to the aging and nutrition community. Emphasis was

focused on understanding the importance of planning, funding, technology, health insurance billing, data

sharing, partnership and staffing needs in order to complete this innovation project.

SUCCESSES AND LESSONS LEARNED

Partnerships

• Sub-contract and BAA agreements needed to be submitted at the time of IRB submission, thus all documents

had to be finalized simultaneously. Given that this process took significantly longer than expected, a lesson

learned for startup projects is to include a minimum of 6 months to foster new relationships, learn institutional

legal and contract restrictions/requirements, and write, submit and receive approval of IRB documentations.

• Partnership with local community organizations has been instrumental to this program as they are deeply

connected with the community and understand the needs, challenges, and resources available to participants.

Community partners were invited to join Taking Charge of Diabetes Advisory Group. Each of these partners

were integrated in the program to receive referrals from enrolled participants in order to provide additional

services including access to nutritious food, health insurance, prescription assistance, transportation, and

housing assistance.

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nutritionandaging.org

This project was supported, in part by grant number 90PPNU0001 from the U.S. Administration

for Community Living, Department of Health and Human Services, Washington, D.C. 20201

ADVICE TO PEERS

Organizations seeking to replicate this project will need to have demonstrated knowledge of and expertise in 

delivering nutrition services for older individuals, as well as a proven track record of successfully administering 

nutrition programs within the Older Americans Act aging services network. 

Funding

• Be sure to factor into overall budget or consider applying for additional funding elsewhere to cover the costs

of any needed project planning time. The time needed to get a project off the ground can be significantly

longer than anticipated depending on legal/contracting processes, IRB application and review, and other

unanticipated institutional restrictions.

Technology

• Consider providing in-home health education using telehealth. Technology can potentially be used to do both

individual and group activities/classes.

• Consider having a robust system to access medical records and billing system for all partners involved in the

project to facilitate referral, scheduling and loop back to provider.

Partnership

• Partner with an organization or health care institutions that has RDs who can provide MNT and capability for

billing services already in place.

• Partner with a local community organization as they are deeply connected with the community and understand

the needs, challenges, and resources available to patients.

Staffing

• Staffing would require a program coordinator to manage the communication needed for all the moving pieces

and partnerships involved as well as ensuring services are provided as proposed.

• Consider integrating the RD as a hospital employee and the health coach as a community organization employee

allowing better integration of roles and servicing the patient, the hospital and the community.

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