CHLPI Hosts the Western North Carolina Diabetes Strategy Forum at UNC-Asheville

CHLPI Hosts the Western North Carolina Diabetes Strategy Forum at UNC-Asheville

by Katerina Souliopoulos, 2014 Summer Intern, Health Law and Policy Clinic

Clinical Fellow Maggie Morgan presents on the importance of integrated, whole-person care for people living with Type 2 Diabetes.

Clinical Fellow Maggie Morgan presents on the importance of integrated, whole-person care for people living with Type 2 Diabetes.

On June 9th, the Center for Health Law and Policy Innovation (CHLPI) hosted the Western North Carolina Diabetes Strategy Forum at UNC – Asheville in order to address diabetes prevention and management throughout the Western region of the state. The population of Western North Carolina has a particularly high rate of diabetes at 12%. Western North Carolina faces particular regional challenges in preventing and managing type 2 diabetes, such as a lack of public transportation to medical services, low access to healthy food, and a shortage of medical providers. The strategy forum convened local diabetes leaders from a range of disciplines including endocrinologists, clinical pharmacists, certified diabetes educators, and community health workers for an in-depth conversation about the current state of the disease in Western North Carolina and how to best move forward.

Harvard Law Professor and Director of CHLPI, Robert Greenwald, kicked off the event along with Patti Doykos, Director of the Bristol-Myers Squibb Foundation. The introductions highlighted the importance of the recommendations within CHLPI’s comprehensive 2014 North Carolina State Report Providing Access to Healthy Solutions (PATHS) – The Diabetes Epidemic in North Carolina: Policies for Moving Forward. Both Greenwald and Doykos emphasized that the Forum is only the first step in identifying opportunities for policy reform and eexpressed commitment to transforming the report’s research into advocacy and reform efforts.

Participants in the Strategy Forum heard from Dr. Wendy S. Lane of the  Mountain Diabetes and Endocrine Center in Asheville about the gaps in care for people living with diabetes. Dr. Lane explained that a combination of providers having little time to spend with patients and a lack of diabetes-specific training and education often resulted in delayed referrals from primary care doctors to specialists, putting patients at risk of developing complications. For example, Dr. Lane related an experience in which a patient came to her that had been living with diabetes for over 18 years. By the time Dr. Lane saw the patient, he had bleeding in his right eye and nerve damage in his legs. During those eighteen years, just one mile from Dr. Lane’s office, his primary care physician had attempted to manage his treatment with a kind of insulin that had been disfavored for at least a decade. Dr. Lane’s anecdote highlights the need for better diabetes-specific training incorporated into medical school curricula, and timely referrals to specialists. Dr. Lane recommended that medical residents spend at least four weeks practicing under trained endocrinologists, especially as diabetes is one of the most common conditions they’ll see as primary care providers practicing in Western North Carolina.

The Forum also included a panel discussing diabetes prevention and management initiatives throughout Western North Carolina. The panel included:

  • · Rick Davis, Executive Director, Graham Revitalization Economic Action Team (GREAT)
    • Presenting on Graham County’s Greenway Project and the Reimagining Robbinsville project. Each project will revitalize Robbinsville’s downtown, while increasing sidewalk connectivity and cultivating a community of walking and biking.
  • · Suzanne Landis, MD, MPH, Director, Division of Healthcare Innovation; Director, Center for Healthy Aging, Mountain Area Health Education Center
    • Presenting on the potential benefits of Accountable Care Organizations (ACOs) within the Western North Carolina hospital network. ACOs are groups of various medical providers who join together to deliver coordinated care to patients in the hopes of increasing quality of care while decreasing cost.
  • · Katie Souris, Coordinator of Preventive Health & Diabetes Wellness and Prevention Program, YWCA of Asheville and WNC
    • Presenting on the YWCA’s Diabetes Wellness and Prevention Program. Participants in the program receive personal fitness training, diabetes education from medical providers and other health professionals, and access to support groups and cooking classes.
  • · Wendy S. Lane, MD, Clinical Endocrinologist & Director of Research, Mountain Diabetes and Endocrine Center

The forum concluded with a roundtable discussion in which participants identified priorities for improving diabetes prevention and management within Western North Carolina in the coming years. Community leaders addressed several themes, such as increasing collaboration and communication among providers and community health resources, educating patients on proper diabetes self-management techniques, and increasing insurance coverage for prevention and management programs. They also learned of one another’s great work within the region and forged new connections that will advance the goal of improving access and quality of diabetes healthcare in Western North Carolina.

North Carolina Launch for Phase II of the PATHS Project

by Qing Qing Miao, 2014 Summer Intern, Health Law and Policy Clinic


Dr. Ann Albright, Director of the CDC’s Division of Diabetes Translation, presents on the efficacy and importance of the Diabetes Prevention Program.

In continuation of its efforts to provide comprehensive policy recommendations for the prevention and management of type 2 diabetes, the Harvard Law School Center for Health Law and Policy Innovation (CHLPI) recently launched its 2014 North Carolina State Report: Providing Access to Healthy Solutions (PATHS) – The Diabetes Epidemic in North Carolina: Policies for Moving Forward. The launch took place in Raleigh, North Carolina and began with a Diabetes Leadership Dinner on May 29th followed by a Strategy Forum on May 30th. Similar to its counterpart New Jersey report released earlier in March, the North Carolina report provides detailed coverage of the current landscape of diabetes care and offers both broad and specific policy initiatives to strength federal, state and local efforts to improve type 2 diabetes care.

Funded by the Bristol-Myers Squibb Foundation through the organization’s Together on Diabetes Initiative, the report comprises the second phase of PATHS’ state-level policy reform initiatives in New Jersey and North Carolina. Selected for their opportunities to receive and implement federal-level recommendations, these pilot states possess both the momentum and infrastructure to sustainably implement findings from the report.

The North Carolina report is the final product of the efforts of the CHLPI Clinical Fellows, Maggie Morgan and Sarah Downer and the clinical student Tiffany Lopinsky. Developed over the course of 18 months, the report incorporates extensive interviews with over 90 key stakeholders and community partners, who shared insights into the barriers involved in mitigating the health impacts of diabetes.

The PATHS report provides both the contextual and structural analysis of institutional systems currently installed within North Carolina and recommends policy to help the state move forward with its health initiatives. Touching upon the social, legal, environmental, and financial dimensions of diabetes care, the report underscores two broad areas of policy: disease prevention and disease management. Detailed recommendations spanned the following topics: increasing economic access to healthy foods for the underserved; improving the food retail and transportation infrastructure to help individuals access healthy foods; implementing early childhood interventions through school food and wellness programs; embracing community resources to build a social support network for patients; implementing a coordinated system of whole-person care involving primary and special care, self-management education, community health workers; and increasing access to health care providers.

CHLPI initiated its launch with a Diabetes Leadership Dinner, inviting key interviewees and other notable partners such as Patti Doykos, the Director of the Bristol-Myers Squibb Foundation. Opening the event with warm introductions was Robert Greenwald, the Director & Clinical Professor of Law at CHLPI. Greenwald introduced the mission of the Center to improve health outcomes and reduce health disparities, highlighted the strategic legal moves and actionable recommendations underlying the report, and put forth the “whole-person patient centered” treatment approach that PATHS advocates. In closing, he emphasized the imperative for community and state support in steering the trajectory of diabetes care as it changes within a rapidly transforming health landscape.

Following Greenwald’s introduction was a keynote address presented by Dr. John Buse, Chair of the National Diabetes Education program. In his presentation titled “A Clinician’s Perspective of Diabetes Priorities in North Carolina,” Dr. Buse underscored studies supporting the efficacy of lifestyle interventions on decreasing the incidence of comorbid diseases. Unfortunately, the populations most vulnerable to diabetes complications are minority groups, which are disproportionately affected by the disease. In North Carolina, diabetes is twice as likely to affect minorities. According to Dr. Buse, segregation and income are the two most prominent factors for health disparities. To eliminate this health gap, he proposed a three-pronged approach of expanding insurance coverage, helping individuals access diabetes self-management education, and developing community health workers & peer support.


Over 75 participants in the Diabetes Strategy Forum rose to their feet and vowed to continue the fight against Type 2 Diabetes in North Carolina.

The Strategy Forum hosted on May 30th allowed CHLPI to present its report to the North Carolina Diabetes Advisory Council (NCDAC), which directly advises the state government on diabetes prevention and management. The forum served a dual function as a platform for the attendees – public health officials, health care professionals, community health workers, and other stakeholders of the state – to prioritize action items surrounding diabetes prevention and management.

Formal events started with the CHLPI team’s presentation of its report before the Diabetes Advisory Council (DAC). Afterwards, the team welcomed the arrival of significant contributors to the Strategy Forum. Patti Doykos and Robert Greenwald led the introductions and directed the audience attention to the final iteration of CHLPI’s presentation. Following the PATHS presentation was the keynote speech given by Dr. Ann Albright, the Director of the Division of Diabetes Translation for the Centers for Disease Control and Prevention. Detailing the trends of diabetes within the last few decades and the trajectory of the disease in the future, Dr. Albright emphasized the importance of evidence-based Diabetes Prevention Programs (DPP) implemented at the state level and scaled at the national level. After presenting the CDC’s own DPP research trial, she made a forceful case for lifestyle change interventions – mediated by the installation of trained health workers – in helping to prevent diabetes and managing pre-diabetes.

The full breadth of current state efforts to prevent and manage diabetes was encapsulated by the four panelist presentations given after the keynote. The last of the panelists, L’Tanya Gilchrist, shared a compelling story of her motivations for working as a clinical assistant health provider at the Durham County Health Center. She recounted her father’s experience with diabetes: at the height of his disease, his complications had necessitated that he receive several amputations. At the climax of her story, Gilchrist determinedly asserted that no patient should ever have to experience what her father had. She described her role as a community health coach – how she is able to assist patients with literacy barriers in providing diabetes self-care and how she connects them to their healthcare providers.

The Forum culminated with a strategy session, an incubator exercise for the different health and policy professionals to distill their ideas about moving forward with diabetes prevention and management. A sense of excitement and reserved optimism characterized the tone of the collaborative work as each group detailed their priorities for diabetes-related policy reform. Themes pervading the exercise ranged from improving the built environment, community zoning involving the partnership of urban planners, and methods to increase community social support. Although conversations about diabetes prevention and management touched on various subjects, the issue of reimbursement for pre-diabetes care was especially prominent, as Medicaid currently does not reimburse for the identification and management of pre-diabetes. This issue guided the forum’s final discussion as multiple attendees highlighted the imperative to expand the health focus to include pre-diabetes.

CHLPI Releases Comprehensive Report on Diabetes in North Carolina


The Center for Health Law and Policy Innovation (CHLPI) of Harvard Law School released its 2014 North Carolina State Report Providing Access to Healthy Solutions (PATHS) – The Diabetes Epidemic in North Carolina: Policies for Moving Forward.

In addition to the full report, the project released the following related materials:
Executive Summary
PATHS North Carolina Fact Sheets:
Background on Type 2 Diabetes in North Carolina
Type 2 Diabetes Prevention
Physical Activity Infrastructure
Healthy Food Access
Type 2 Diabetes Self Management

The report is funded through a grant from the Bristol-Myers Squibb Foundation and was released during the CHLPI Diabetes Leadership Dinner on May 29 and Strategy Forum on May 30 in Raleigh. The report was also presented to the North Carolina Diabetes Advisory Council (NCDAC) at its spring meeting on May 30. The NCDAC advises the state government on diabetes prevention and management.

The report is a result of extensive research and over 90 interviews with policymakers, government agencies, and nonprofit organizations that are playing a role in the state’s diabetes response. It provides a comprehensive summary of the type 2 diabetes landscape in the state, including a discussion of the policies that impact type 2 diabetes and policy recommendations to help reduce its prevalence and consequences. It was created to empower diabetes advocates and local and state governments in their planning to promote positive policy change and efforts to address the impact of type 2 diabetes within NC communities. “Diabetes is a rapidly growing affliction in North Carolina with rates having almost doubled since the 1990s,” said Robert Greenwald, Director of CHLPI and Clinical Professor of Law at Harvard Law School. “These numbers continue to grow, and our hope is that the report will inspire a collaborative, integrated approach that supports improvements to the built environment, access to healthy food and education programs, and access to necessary medical and lifestyle interventions.”

To launch the report, CHLPI hosted the PATHS Diabetes Leadership Dinner on Thursday, May 29, and the North Carolina PATHS Diabetes Strategy Forum on Friday, May 30. The events convened elected and appointed officials and healthcare and nonprofit leaders to discuss the report’s findings and identify opportunities for synergies based on the report’s recommendations, which included:

  1. promoting team-based, whole-person models for delivery and financing of diabetes care;
  2. increasing access to diabetes prevention and self-management programs;
  3. expanding evidence-based telemedicine programs to help alleviate provider shortages;
  4. expanding access to durable medical equipment and insulin;
  5. improving behavioral health services for people with diabetes;
  6. increasing economic access to healthy food;
  7. increasing geographic access to healthy food;
  8. increasing opportunities for physical activity in the built environment;
  9. improving nutrition and cooking education opportunities; and,
  10. expanding early childhood, school food, nutrition, and wellness programs.

To continue its efforts, CHLPI will host the Western North Carolina Diabetes Strategy Forum on June 9 at UNC – Asheville. The event will convene leaders in the Western region and focus on issues specific to rural communities.

PATHS staff member Sarah Downer was interviewed and quoted for the June 2, 2014 news article on North Carolina Public Radio “Report: Left Unchecked, Diabetes will Cost NC Billions.”

From Open Streets to Cooking Classes

From Open Streets to Cooking Classes, New Jersey PATHS Speakers Highlight Innovative Healthy Solutions

by Alexandra Maron, JD’15, Harvard Law School

As a student in the Center for Health Law and Policy Innovation at Harvard Law School, I was fortunate to have the opportunity to attend the New Jersey Diabetes Leadership Forum in Trenton, New Jersey on March 27, 2014. The event featured the release of the Center’s 2014 New Jersey State Report: Providing Access to Healthy Solutions (PATHS) funded by the Bristol-Myers Squibb Foundation in an effort to address type 2 diabetes in the state.

The Forum featured two panels aimed at presenting what is currently being done in New Jersey to improve the type 2 diabetes situation in the state in addition to opportunities for improvement and ways to work together to find a solution. The first panel, which took place in the morning, was devoted to discussing the current initiatives and programs that different cities and counties within New Jersey have implemented to promote health and wellness.


From left: Panelists Mark Humowiecki, Charles Brown, Kim Fortunato, Elizabeth Reynoso, and Dr. Kemi Alli.

Each panelist presented what their organization is currently doing for individuals in New Jersey to help improve their health and physical activity. First, Charles Brown of the Voorhees Transportation Center at Rutgers University discussed Complete Streets, Safe Routes to School, and other programs to make it easier and safer for people to walk and cycle through their communities. One of the programs that stood out to me was the “open streets” program called the “New Brunswick Ciclovia,” which opened up streets to pedestrians and bikers and closed them to drivers. Over 4,000 people attended Ciclovia in New Brunswick on October 6, 2013 and the event allowed individuals to play in the streets and see new stores, providing the opportunity both for physical activity and exploration of the community in which residents live. According to Mr. Brown, more than 50% of the Latino community of New Brunswick participated in the event. There are additional Ciclovia events scheduled for May, July, and October of 2014. I think that the Ciclovia events are a wonderful place for cities in New Jersey interested in making an impact on obesity and diabetes to start. These events not only provide the opportunity to individuals who might not feel as though their neighborhood is safe to play and be active outside to explore their communities, but also allow them to partake in events with other individuals who live around them to be active and healthy together. By implementing similar open streets programs in other cities in New Jersey, individuals may start to become more comfortable in the communities in which they live while having the opportunity to walk, run, or bike without fear of oncoming traffic.

Another panelist from the first panel who described a program that really stood out to me was Kim Fortunato, the Director of Campbell Healthy Communities at Campbell Soup Company. She discussed the strategy areas of the Campbell Healthy Communities Initiative, a $10 million corporate program aimed at reducing childhood obesity and hunger in Camden, New Jersey. One program focus has been on improving food access in Camden with the addition of healthy foods and cooking demonstrations at corner stores to help improve nutrition in Camden. The initiative funds about thirty healthy corner stores in the city. I think that taking action and going into the corner stores in Camden is a wonderful idea, since a lot of the residents of Camden rely on these corner stores for the majority of their food needs. By working with these stores to stock healthier options and providing the tools that individuals need to be able to prepare healthy foods, this initiative is making a real difference in the community. The Campbell Healthy Community Initiative is also focused on nutrition education through family cooking classes. Similar to the cooking demonstrations being provided in the corner stores, cooking classes for families are also an important step in not only providing healthier options to individuals to help lessen the obesity and diabetes epidemic, but also in implementing the healthy options in the home. The family cooking demonstrations can really provide a way for individuals to learn more about healthy food preparation in a fun, interactive way that can help individuals and their families lead healthier lifestyles.


From left: Panelists Teresita Lawson, Bill Lovett, Francine Grabowski, Darrin Anderson, and Dr. Rina Ramirez.

The second panel was about improving the diabetes prevention and treatment programs in New Jersey that provide access to key services.

Darrin Anderson, the State Deputy Director of the New Jersey Partnership for Healthy Kids and the Associate Executive Director of the New Jersey YMCA State Alliance, discussed the New Jersey Partnership for Healthy Kids, whose goal is to evaluate and improve the environment in which New Jersey children live. He noted that without changing the environment that kids are living in, which is often “contaminated,” it will be impossible to make a marked impact on their health and physical activity. This idea really resonated with me because for individuals struggling to change their lifestyle to become healthier people, being constantly faced with temptations to choose less healthy options would be incredibly difficult. If instead communities were more supportive of healthy lifestyle changes, then perhaps children could have an easier time getting more physical activity and making healthier choices in terms of nutrition. Mr. Anderson also discussed the need to create School Health Councils to improve the climate of schools to cultivate healthy and active students. He spoke of the importance of maintaining a positive atmosphere in schools for students when working towards better health. By engaging teachers, faculty, and school administrators in the process of building a healthy, active school community, students will hopefully learn the skills and ways of life most conducive to being healthier individuals. Hopefully these steps will help to reduce the incidence of childhood obesity and diabetes in New Jersey.

Additionally, Teresita Lawson, a Clinical Pharmacist at the Zufall Health Center, and Dr. Rina Ramirez, the Chief Medical Officer at the Zufall Health Center, presented findings from their study of the Zufall Health Center’s integration of pharmacists into coordinated care teams through a program called Project IMPACT Diabetes. Evidence from this project showed that clinical pharmacy services, including face-to-face encounters and frequent follow up with patients, yielded better health outcomes and improved levels of cholesterol and blood pressure after only one year. However, because pharmacist visits are not a billable service, the program’s sustainability is in question. The lack of insurance coverage of pharmacist visits is a potential barrier to the future implementation of similar coordinated care integration. Additionally, while evidence of the program’s success in such a short period of time is promising, it will be interesting to see if there are additional longer term impacts of adding pharmacists to care teams.

The panels were incredibly enlightening and each panelist’s presentation laid the groundwork for possible collaboration and change in New Jersey, which was exciting and motivating to all of the attendees, including myself. I really enjoyed hearing about all of the different programs currently being run in New Jersey to help make residents healthier and to combat the diabetes epidemic in New Jersey. I am very much looking forward to seeing what is accomplished in the state in the coming months and years to decrease the rates of obesity and diabetes in New Jersey.

Statistics Are Not the Whole Story

Statistics Are Not the Whole Story: Dr. Anthony Cannon’s Keynote at New Jersey PATHS Event Makes the Diabetes Epidemic Personal

by Taylor Bates, JD’15, Harvard Law School


Keynote Speaker Dr. Anthony Cannon describes the economic and human costs of diabetes.

The New Jersey Diabetes Leadership Forum keynote presenter was Dr. Anthony Cannon, who discussed the economic impact of type 2 diabetes in New Jersey. Dr. Cannon made clear that prevention and effective treatment could significantly cut the costs of treating diabetes, but that without reforms New Jersey would face enormous costs to combat the disease. Dr. Cannon’s most striking figures included an estimated $68.6 billion in indirect diabetes costs per year, and a cost of emergency room care for untreated diabetes of over $1,250 per hour. Dr. Cannon, a former member of the American Diabetes Association’s African-American Initiative Committee, also made a clear case for outreach to minority communities, because uninsured African-Americans visit the emergency room 75% more than similarly situated populations. As an endocrinologist, Dr. Cannon grounded his economic analyses in experience treating patients face-to-face, and linked poor diabetes management with doctors who failed to treat their patients with respect. He identified denial, depression, and despair as major obstacles to patients receiving the best diabetes treatment, but expressed hope that the state could combat diabetes through better policy going forward.

The most striking aspect of Dr. Cannon’s presentation was his ability to link face-to-face interaction with the overall economic costs of diabetes. Dr. Cannon’s presentation would have been powerful even if limited to the statistics and analysis he presented, but those costs become palpable when he told the story of a woman who had gone untreated because she felt shamed and unwelcome at her previous doctor’s office. The woman, who had begun to present serious “Charcot foot” swelling symptoms, was quickly able to regain control of her blood glucose levels with medication and lifestyle change.  While she was able to avoid the immediate health risks of diabetes, her mistreatment at a previous doctor’s office risked serious harm to her health and enormous medical costs. Dr. Cannon used this example to call for better training and engagement between providers and patients, with greater understanding of the human touch when treating diabetes.

Applied to New Jersey’s diabetes challenges, Dr. Cannon’s comments underscore the need for improved communication among providers, since a more robust system of providers might have caught the failure of her first doctor. Patient-Centered Medical Homes and Medicaid Health Homes are both significant ways to improve communication among providers, and prevent the serious health risks and costs that accompany untreated diabetes. On the patient side, education programs like DSME (Diabetes Self-Management Education) and DPP (the Diabetes Prevention Program) might have helped the patient recognize her symptoms as serious much earlier, or provided coping strategies to deal with an unhelpful doctor and the stress of a chronic illness. Clearly, New Jerseyans will need more efficient and effective medical care to avoid the worst human and economic costs of diabetes, but well-researched solutions already exist to tackle these problems.

PATHS Releases Comprehensive Diabetes Report

The project “PATHS: Providing Access to Healthy Solutions” has just released the report An Analysis of New Jersey’s Opportunities to Enhance Prevention and Management of Type 2 Diabetes. The Executive Summary and Full Report are available as well as the following project materials:




PATHS New Jersey Fact Sheets:
Background on Type 2 Diabetes in New Jersey
Background Fact Sheet
Type 2 Diabetes Prevention
The Diabetes Prevention Program
Physical Activity
Complete Streets Program
Healthy Food Retailers
Food Hubs
National School Breakfast Program
Type 2 Diabetes Management
Diabetes Self-Management Education
Medicaid Care Management
Medicaid Health Homes
Community Health Workers
The Patient Self-Management Program

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