Total Dollars Awarded by the Robert Wood Johnson Foundation (9/1/01 to 8/31/04): $ 318,000

Grantee: Corporación de Servicios de Salud y Medicina Avanzada (COSSMA), Cidra, PR

Co-funders: Puerto Rico Community Foundation, Johnson & Johnson Community Health Care Program, National Association of Community Health Centers (AmeriCorps Program), “Aliados por Nuestro Bienestar” Johnson & Johnson de Puerto Rico, Glaxo Smithkline

Primary Objective: To provide 100% access to the patients identified to the Chronic Disease Prevention and Control Project (CDPCP) to be developed with “Health Promoters”, COSSMA interdisciplinary health care team and community collaborators. This way we can improve the health care for people with chronic health conditions specifically with asthma, diabetes and hypertension.

Accomplishments:

• Technical Assistance by Johns Hopkins in program evaluation.
• Asthma Summer Camps impacting 98 children in 2002 and 45 in 2003.
• Recruitment and training of seven peer mentors that are our link to the community.
• Moved to facilities that provided adequate office spaces.
• Served 4,781 persons with chronic diseases through June 2003.
• Conducted 25 home visits for uncontrolled clients.
• Diabetes patients are receiving glucometers as an incentive to complete the self management program.
• Peak Flow meters are provided to asthmatic patients.

Challenges:

• Recruitment of Case Manager – RN
• Physician referrals
  • Involve the physician in referral of the clients to the educational activities. (They hand an invitation directly to the client and the nurse gives them contact information for follow up by health promoters.

Lessons Learned: The decision to have an RN as the Case Manager instead of another health provider. The RN will help the team in the every day training, home visits and monitoring of patients

Future Plans:

• Establish community exercise groups.
• Recruit and train 18 additional peer mentors.
• Reach other communities to sustain project.
• Have a nurse available to test patients’ blood sugar and blood pressure.
• Provide box pills to all patients to carry at all times.
• The nutritionist developed recommended menus based on patients’ conditions.
• Offer mental health educational activities.

Sustainablilty: To develop the CDPC instructional module to facilitate the implementation of the Project in other communities.

Graduates 2003