The 131st Annual Meeting (November 15-19, 2003) of APHA

The 131st Annual Meeting (November 15-19, 2003) of APHA

3019.0: Monday, November 17, 2003 - 8:54 AM

Abstract #59974

Lessons learned from a two-year, community-based risk management program for low-income patients at risk for diabetes, hypertension and hyperlipidemia: The Next Steps Project in Sonoma County, CA

Maureen Flynn-Garcia, PHN1, Flor I. Serrano, CHOW2, Amy M. Carroll, MPH3, Sarah E. Samuels, DrPH3, Norma Ellis, MPH4, Barbara Graves5, and Adrianne Bowes, RN6. (1) Next Steps Project, Department of Health Services, Sonoma County California, 18206 Clayton Ave., Sonoma, CA 95476, 707-939-8216,, (2) Community Health Outreach, Petaluma Health Center, 1301 Southpoint Blvd, Petaluma, CA 94954, (3) Samuels & Associates, 1204 Preservation Park Way, Oakland, CA 94612, (4) Department of Health Services, Sonoma County, 625 Fifth Street, Santa Rosa, CA 95404, (5) Prevention and Planning Division, Sonoma County Department of Public Health, 1030 Center Drive #C, Santa Rosa, CA 95403, (6) Redwood Community Health Coalition, 1180 Fourth Street, Santa Rosa, CA 95404

PURPOSE: The California Endowment and the Sonoma County Department of Health Services jointly funded the Next Steps Project for two years to decrease cultural disparities and enhance client care coordination and outreach services for prevention, treatment, and lifestyle change education for low-income, ethnic minority clients at-risk for chronic disease. Collaborative health care teams at 8 health centers throughout Sonoma County worked together to identify, refer, and increase the level of knowledge and motivation in newly diagnosed patients to maintain preventive health practices and disease self-management. METHODS: The goal of the evaluation was to measure the impact of program through: 1) demographic, behavioral and clinical outcomes data tracked via an on-going client encounter database; 2) surveys conducted with program stakeholders regarding their perceptions and experiences collaborating with Next Steps Project activities; 3) exit interviews conducted with clients about their program experiences; and 4) reflections on program lessons learned by program Community Health Outreach Workers. FINDINGS: Preliminary findings indicate that before budgetary restrictions affected Next Steps and the majority of staff positions ended in June of 2003, the program was well-received by program stakeholders and clients, and was able to demonstrate significant changes in behavioral and clinical outcomes related to chronic disease management. Final data analyses, stakeholder, and exit survey results will be presented in the session, along with specific program and policy recommendations on how to incorporate sustainable and affordable program components into local health center delivery systems with current budget constraints.

Learning Objectives:

Keywords: Community Outreach, Home Visiting

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.

Obesity, Diabetes and Nutrition: Improving Services/Changing Lifestyle Behaviors

The 131st Annual Meeting (November 15-19, 2003) of APHA