Seton Health System

Seton Health is part of Ascension Health system, which serves a large swath of poverty-stricken areas in northeastern New York characterized by higher-than-average levels of poverty, vacant housing, and female-led households, and low levels of education.

Diabetes disproportionately affects low-income populations, which have much higher rates of diabetes-related complications and mortality. In 2008, NYHealth awarded Seton Health a grant to use an established parish community nurse model and its outpatient diabetes education program to create its Defy Diabetes initiative and address the needs of people with diabetes. NYHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

A keystone of the initiative will be expanding Seton Health’s existing Faith Community Parish Nurse Program. As part of the proposed project, six additional Faith Community parish nurses will be trained and deployed into the community. These nurses combine professional nursing with health ministry by emphasizing “high talk” verses “high tech” approaches toward health and healing. The nurses will employ the STEP initiative (Screening, Testing, Education, Prevention activities in line with the National Diabetes Education Program) in six target communities and will work with diabetics and at-risk diabetics to make modest lifestyle changes that can prevent or delay the onset of Type 2 diabetes. The program will target an estimated 1,000 congregants with either diagnosed diabetes or pre-diabetes indicators. Services will include referrals to primary care, healthy living classes, and referrals to Seton Health’s outpatient diabetes education program. DEFY DIABETES! will also work with approximately 25 primary care practices in these six communities to expand diabetes management activities. It will identify in-house practice “champions” to increase primary care compliance with American Diabetes Association recommendations. Along with the parish nurses, these “champions” will serve to populate patient data in a Web-based diabetes data registry to track progress and outcomes over time.