Clinic to Community: Achieving Health Equity in the Southern United States

The Mississippi Public Health Institute (MSPHI) collaborated with Duke University Medical Center to implement part of “From Clinic to Community: Achieving Health Equity in the Southern United States” – part of the Centers for Medicare and Medicaid Services Health Care Innovation Award.

This CMS Health Care Innovation Challenge Award grant provides targeted, patient centered care to people with diabetes in Quitman County. These services are provided through the patient’s primary care setting to create a locally adapted version of a medical home. Programs also diminish the severity of the disease and reduces the number of hospital visits among participants. These improvements will help to achieve health equity in the Southeast.

There are four sites of this project across the southeast United States – MSPHI’s project is in Quitman County, MS. We partnered with Quitman County health and community organizations, faith-based groups, local government, and community members with the goal of reducing morbidity and mortality from type 2 diabetes by connecting patients to community resources and providing home visits.

We want adults living with type 2 diabetes to:
• Improve health outcomes,
• Improve quality of life,
• Improve glycemic control, and
• Improve diabetes.

The activities associated with this project include:
• Provide home visits,
• Assist with developing an action plan to improve care,
• Link patients to necessary social services, and
• Provide follow-up care and health education.

For more information please contact Brooks Ann Gaston, brooksanngaston@gmail.com.

Quitman County clinic staff, MSPHI staff, and Duke University Medical Center Staff at Family Medical Center in Quitman County. (front row) Ashley Dunham; Jan Collins, RN; (back row) Rebecca Crane, PharmD; Rockell Thomas; Richard Waller, MD; Brooks Ann Gaston; Robert Califf, MD; and Ricky Boggan, JD.

Quitman County clinic staff, MSPHI staff, and Duke University Medical Center Staff at Family Medical Center in Quitman County. (front row) Ashley Dunham; Jan Collins, RN; (back row) Rebecca Crane, PharmD; Rockell Thomas; Richard Waller, MD; Brooks Ann Gaston; Robert Califf, MD; and Ricky Boggan, JD.

MSPHI and Duke University Medical Staff meeting with University of Mississippi School of Pharmacy Staff: Leigh Ann Ross, PharmD; Ricky Boggan, JD; Robert Califf, MD; and Brooks Ann Gaston.

MSPHI and Duke University Medical Staff meeting with University of Mississippi School of Pharmacy Staff: Leigh Ann Ross, PharmD; Ricky Boggan, JD; Robert Califf, MD; and Brooks Ann Gaston.

MSPHI and Duke University Staff at Quitman County Hospital: (from left) Brooks Ann Gaston; Robert Califf, MD; Steve Nichols; Shelley Rusincovitch; Ricky Boggan, JD.

MSPHI and Duke University Staff at Quitman County Hospital: (from left) Brooks Ann Gaston; Robert Califf, MD; Steve Nichols; Shelley Rusincovitch; Ricky Boggan, JD.