Iowa Roadmap to Improve Population Health

The Iowa SIM Roadmap to Improve Population Health will focus on decreasing the prevalence and incidence of diabetes in Iowa. Diabetes is a chronic illness that is diagnosed based on a person having elevated levels of blood sugar (blood glucose). Most people with diabetes find its management challenging and a lifelong commitment.

The SIM project will positively impact health outcomes for the approximately 211,000 Iowans who live with diabetes, the nearly 200,000 with pre-diabetes, and the estimated 9 out of 10 adults with prediabetes that don’t know they have it.

Framework for Population Health Improvement

System-level Care Coordination & Management:  

Care coordination for the target population will be enhanced through 1) focusing provider efforts on improving health outcomes for diabetes in pilot communities (C3s) by enhancing the existing value based payment structure to include clinical quality measure(s) potentially related to diabetes care; and 2) having a health information technology infrastructure that supports care coordination.

Evidence-based Care and Patient Self- Management and Support:

The Iowa SIM project will increase the intensity and geographical spread of the tactics contained in the Diabetes and other statewide strategy plans through the 1) C3 “population based, community applied” interventions, and 2) promotion of the tactics to communities identifying diabetes as a need in their Community Health Needs Assessment and Health Improvement Plans (CHNA &HIP).

Linkages to Community-Based Resources to Address Patients’ Social Needs:

The Iowa SIM project will address SDHs in three ways. 1.) The development and/or enhancement of referral networks, in C3 regions, that address social needs for individuals having or at risk of having diabetes. Technical assistance will be provided to the C3s so the referral systems that are implemented are effective and efficient. 2.) SDH interventions will be implemented in the Iowa SIM project is through expanding the use of the Assess My Health (AMH) health risk assessment (HRA) by linking it to value based purchasing for the Medicaid Managed Care Organizations with special attention to the Health Confidence measure. Expansion to additional payers or to the general population is also being explored. 3.) The aggregated SDH data collected from the AMH completion will be shared with stakeholders to inform decision makers about the SDH needs across Iowa.

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