Project Title: "From clinic to community: achieving health equity in the southern United States"
Geographic Reach: Mississippi, North Carolina, West Virginia
Funding Amount: $9,773,499
Estimated 3-Year Savings: $20.8 million
Led by Duke University, the Southeastern Diabetes Initiative (SEDI) is a project that supports integrated teams implementing a model for improving health outcomes and quality of life for those suffering from type 2 diabetes mellitus (T2DM) in the Southeastern United States. The majority of funds are being used to (1) harvest data from all electronic sources in each county to create a comprehensive, integrated data warehouse to accurately reflect clinical and social data that can be represented at the individual, neighborhood, and community level, and (2) use that data to implement spatially-enabled informatics systems that risk stratify patients and neighborhoods, allowing implementation of an intense clinical intervention from a multi-disciplinary team that provides care to the highest risk patients as well as additional individual and neighborhood interventions to moderate risk patients and neighborhoods - providing real-time monitoring of individuals and populations with T2DM and serving as the basis for decision support and evaluation of interventions. A spatially-enabled analytical platform has been created via an electronic health record integrated data warehouse that covers the vast majority of Durham and Cabarrus County, North Carolina residents (representing urban and rural African Americans and Hispanics in North Carolina), Mingo County, West Virginia, and Quitman County, Mississippi (rural African Americans in the Mississippi Delta). Our collaborative team includes the Mississippi Institute for Public Health; Center for Rural Health at Joan C. Edwards School of Medicine, Marshall University; the Mingo County, West Virginia Diabetes Coalition and Williamson Health and Wellness Federally Qualified Health Center in Williamson, West Virginia; the Appalachian Regional Commission; the Durham County Department of Health in Durham, North Carolina; Duke University Medical Center; the Cabarrus Health Alliance in Kannapolis, North Carolina and Cabarrus Community Health Centers in Concord, North Carolina; and the National Center for Geospatial Medicine at the University of Michigan.