From Profile to Plan: Three Actions a Health System Can Take Where Diabetes Hospitalizations Concentrate
Student Name
American College of Education
HLTH5623: Epidemiology and Public Health for Healthcare Administrators
Module 6 Assignment
Instructor Name
June 5, 2028
The Findings That Drive Action
The population profile of Brookfield County, a fictional county of about 340,000 people served by the regional health system in this course, produced four findings that matter for action. About 31,000 adults live with diagnosed diabetes. Estimated prevalence is highest, at more than 17 percent, in three east-side urban tracts. Residents there earn less, go uninsured more often and own fewer cars than anywhere else in the county. And their residents, about 6 percent of the county's adults, account for 17 percent of admissions for diabetes complications and amputations, the kind of hospitalization that ongoing outpatient care can often prevent.
Those findings point away from a countywide campaign and toward a focused effort where the gap between burden and care is widest. The system's target is to reduce admissions for diabetes complications among east-side residents by 20 percent within three years, from about 330 admissions a year to about 265, while maintaining progress elsewhere. A population profile earns its keep when it tells a health system where not to spread its resources thin.
Action One: Community Health Workers
The first action is a community health worker program for adults with diabetes in the three tracts who have had an emergency visit or admission in the past year, about 600 people. Community health workers, hired from the neighborhoods they serve, would help patients with the practical barriers the profile identified: arranging transportation, applying for coverage, obtaining medications and supplies and getting to follow-up appointments. Kangovi et al. (2018) tested a standardized community health worker intervention for low-income patients with chronic conditions across primary care practices in a randomized trial. The intervention did not change the primary outcome, self-rated physical health, but patients who received it reported higher quality of care, spent fewer total days in the hospital and had lower odds of repeat hospitalization.
Six community health workers, each supporting about 100 patients with diabetes and other chronic conditions, supervised by a social worker, would cost about $510,000 a year including salaries, benefits, supervision and transportation assistance. The measure of success is admissions for diabetes complications among enrolled patients compared with a matched group of eligible patients enrolled later, along with the share of enrolled patients with a primary care visit every six months.
Action Two: A Neighborhood Clinic Site
The second action addresses access directly. The nearest system primary care clinic to the east-side tracts is 5 miles away by road and about 55 minutes by bus with one transfer, and 16 percent of households in the tracts have no vehicle. The system would open a part-time primary care and diabetes education site in a community health center or church partner's space within the tracts, staffed three days a week by a nurse practitioner, a certified diabetes educator and a medical assistant, with laboratory draws and foot and eye screening on site.
The estimated annual cost is about $620,000, partly offset by visit revenue from patients with coverage. Its measures are the number of distinct east-side patients with diabetes seen each quarter, the proportion with an A1c test in the past six months and the proportion receiving annual foot and retinal examinations, the preventive services most directly linked to avoiding amputation and vision loss.
Action Three: Prioritizing the Prevention Program
The third action connects this plan to the diabetes prevention program evaluated earlier in the course. The system has decided to expand the program to all 22 clinics in a staged, randomized order. This plan recommends that the neighborhood clinic site and the two clinics closest to the east-side tracts be placed in the first group, while preserving randomization among the remaining clinics, and that sessions be offered in the evenings at the neighborhood site. Evaluation of the national program found that attendance drives results, with participants losing more weight for each additional session attended (Ely et al., 2017), so reducing the travel and schedule barriers that limit attendance in these tracts is likely to matter as much as offering the program at all.
Because this action changes the rollout order rather than adding a new program, its additional cost is small, about $40,000 a year for evening staffing. Its measures are enrollment among east-side adults with prediabetes and the proportion completing at least 16 sessions.
Sequencing and Partnerships
The actions are sequenced so that each supports the next. Community health workers begin first, because they can start within three months and will identify the patients most likely to use the neighborhood site. The neighborhood site opens in month six, once a partner space is secured. The prevention program starts at the site in month nine. The health system should not act alone: the county health department already runs a food access program in two of the three tracts, and a formal partnership would allow community health workers to connect patients with it. A scientific review of social determinants and diabetes concluded that addressing food, housing, transportation and health care access together is necessary to reduce disparities in outcomes (Hill-Briggs et al., 2021), which the partnership begins to do.
Risks and What Would Change the Plan
The plan faces three main risks. The first is recruitment: community health worker programs depend on hiring people trusted in the neighborhood, and the system's usual hiring requirements, such as prior health care experience, could screen out the best candidates. The plan therefore asks human resources to create a job description that values lived experience and community relationships over clinical credentials. The second is attribution: admissions for diabetes complications are influenced by many factors, and a decline could reflect changes in coding, in coverage or in another provider's services. The evaluation will compare the east-side tracts with similar tracts in a neighboring county without the program, using the same state discharge data, to separate the plan's effect from regional trends.
The third risk is sustainability. The plan's annual cost of about $1.2 million is only partly offset by visit revenue, and the system's finance committee will expect evidence of reduced admissions before continuing it beyond the first three years. Each action has an early measure that can be read within six to twelve months, and the plan commits to a review at eighteen months. If community health worker enrollment is below 60 percent of eligible patients or the neighborhood site sees fewer than 250 distinct patients with diabetes in its first year, the system will redesign that component rather than continue it unchanged.
Conclusion
The profile showed where diabetes hospitalizations concentrate and why. The plan answers with three targeted actions: community health workers for high-risk patients, a neighborhood clinic site that removes a 55-minute bus trip from routine care and an early, accessible start for the prevention program. Together they cost about $1.2 million a year, and each has a measure the system can read within a year. The three-year target, a 20 percent reduction in complication admissions in the east-side tracts, is ambitious but grounded in the evidence and in a clear understanding of where the gap lies.
References
Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A national effort to prevent type 2 diabetes: Participant-level evaluation of CDC's National Diabetes Prevention Program. Diabetes Care, 40(10), 1331-1341. https://doi.org/10.2337/dc16-2099
Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2021). Social determinants of health and diabetes: A scientific review. Diabetes Care, 44(1), 258-279. https://doi.org/10.2337/dci20-0053
Kangovi, S., Mitra, N., Norton, L., Harte, R., Zhao, X., Carter, T., Grande, D., & Long, J. A. (2018). Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: A randomized clinical trial. JAMA Internal Medicine, 178(12), 1635-1643. https://doi.org/10.1001/jamainternmed.2018.4630
How this HLTH 5623 Module 6 example is structured
HLTH 5623 Module 6 usually converts the analysis into something a health system would act on; your classroom's instructions decide the format and level of detail. This example restates only the findings that drive action, sets a target for the system, then describes three actions with the evidence behind each, what it costs and how it will be measured. A sequencing section explains why the actions are ordered as they are, and the conclusion states what the system should expect in the first year. Linking every action to a specific finding from the profile is what makes the plan epidemiologically grounded rather than a list of good ideas.
HLTH5623 Module 6 questions, answered
What does HLTH5623 Module 6 usually ask for?
HLTH5623 Module 6 usually asks students to turn their epidemiologic analysis into recommendations a health system could act on. Many sections expect actions to be linked to specific findings, supported by evidence and paired with measures. Your classroom's instructions decide the format, which may be a plan, a memo or a presentation.
How do I connect epidemiologic findings to action?
Start from where the burden concentrates and why, then choose actions that address those causes in those places. For each action, cite evidence that it works, estimate its cost and name a measure that will show whether it is working. Avoid general campaigns that spread resources evenly when the data show concentrated need.
Should I report studies that had mixed results?
Yes, accurately. If a trial found no effect on its primary outcome but benefits on secondary outcomes, say so. Honest reporting of mixed evidence makes a plan more credible and helps decision makers set realistic expectations for what an action will achieve.
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