What is an NTTAP?
NTTAPs – National Training and Technical Assistance Partners – are HRSA-funded organizations that provide training and technical assistance to health centers on a wide range of topics. Each NTTAP is funded to provide their expertise around the health needs of a particular “special or vulnerable population,” as defined by HRSA. In 2021, there were 14 NTTAPs serving on the Diabetes Task Force. Here are each of the NTTAPs, with the special population that they support through their HRSA grant funding, and their websites.
Association of Asian Pacific Community Health Organizations, serving Asian American, and Native Hawaiian, and other Pacific Islander communities, www.aapcho.org.
Corporation for Supportive Housing, serving people without stable housing, www.csh.org.
Farmworker Justice, serving agricultural workers, www.farmworkerjustice.org.
Health Outreach Partners, serving all low-income, vulnerable, and underserved populations, www.outreach-partners.org.
MHP Salud, focused on Community Health Workers serving underserved Latinx communities, www.mhpsalud.org.
Migrant Clinicians Network, serving migratory and seasonal agricultural workers, www.migrantclinician.org.
National Center for Equitable Care for Elders, serving older adults, ece.hsdm.harvard.edu.
National Center for Farmworker Health, serving agricultural workers, www.ncfh.org.
National Center for Health in Public Housing, serving residents in public housing, www.nchph.org.
National Health Care for the Homeless Council, serving people without stable housing, www.nhchc.org.
National LGBTQIA+ Health Education Center, serving LGBTQIA+ people, www.lgbtqiahealtheducation.org.
National Network for Oral Health Access, focused on supporting safety-net oral health programs, www.nnoha.org.
National Nurse-Led Care Consortium, provides nurse-led community health services, www.nurseledcare.phmc.org.
School-Based Health Alliance, serving school-aged children, www.sbh4all.org.
The Farmworker Health Network
The Farmworker Health Network (FHN) is a network of the five NTTAPs that have a focus on migratory and seasonal agricultural workers plus the National Association of Community Health Centers. MCN, Farmworker Justice, MHP Salud, Health Outreach Partners, National Association of Community Health Centers, and National Center for Farmworker Health have worked closely for many years to support health centers in meeting the needs of the agricultural worker population. All the members of the FHN are participating in the Diabetes Task Force. Learn more about the FHN and access resources that each of the FHN partners has developed: www.migrantclinician.org/FHN
In 2016, Migrant Clinicians Network reapplied for a grant from the Health Resources and Services Administration (HRSA) to continue providing training and technical assistance to health centers across the US as a National Training and Technical Assistance Partner (NTTAP – see text box for more information). MCN is one of 14 NTTAPS, 13 of which are funded by HRSA to assist health centers in meeting the health needs of patients who are part of “special and vulnerable populations”—segments of the US population that have increased health needs due to their particular circumstances. These populations are migratory and seasonal agricultural workers; individuals experiencing homelessness; Asian Americans, and Native Hawaiians and other Pacific Islanders; residents of public housing; older adults; school-aged children; and lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minority people. These populations have special health needs, social determinants of health, and access issues that require unique strategies on the part of the clinician and health center. NTTAPs support health center staff through training and technical assistance to inform clinicians and other staff, share best practices, remove barriers to care, and, ultimately, to improve the health of patients.
As one focus area included in the new round of funding in fiscal year 2017, HRSA requested that the NTTAPs help health centers improve patients’ diabetes health outcomes by improving hemoglobin A1c testing and glucose control. The hemoglobin A1c is a test that indicates a patient’s average blood sugar level over a period of three months. This test is used to diagnose prediabetes and diabetes, and monitor diabetes control among those who are diagnosed with diabetes. Diabetes is a disease that affected 34.2 million US residents in 20201 and 2.5 million health center patients in 2019,2 and hits some special populations particularly hard. HRSA not only requested a focus on diabetes; it also required collaboration among the NTTAPS on the topic.
Migratory and Seasonal Agricultural Workers, Asian Americans, and Native Hawaiians and other Pacific Islanders: Unique Populations, But All Need Diabetes Focus
Through its HRSA funding, MCN focuses on migrant and seasonal agricultural worker health. Due to a lack of data, migrant and seasonal agricultural workers have an unknown burden of diabetes, but approximately 83% identify as Hispanic or Latinx; therefore, data from self-identified Hispanics often serve as a proxy. Self-identified Hispanic people are 1.3 times more likely than non-Hispanic whites to die from diabetes and Hispanic adults are 70% more likely than non-Hispanic whites to receive a diagnosis of diabetes from a clinician.3 Migratory and seasonal agricultural workers are at an additional risk of diabetes due to exposure to certain pesticides, which have been shown to increase the risk of diabetes.4 Further, poverty, rural locations, transportation issues, and food deserts limit agricultural workers’ ability to access healthy foods. Even those who plant and harvest fruits and vegetables every day at work may struggle to access or afford those same foods for their homes. Consequently, MCN has focused on diabetes for decades to support clinicians who serve migrant and seasonal agricultural worker patients with diabetes and who encounter additional struggles like migration and poverty that limit patients’ ability to continue their diabetes education, maintain health regimens, or consistently access insulin prescriptions. MCN’s popular low-literacy, Spanish-language diabetes comic book, released in 2020, is an example of materials developed with the agricultural worker in mind. (See link to the downloadable comic book in Resources.) Additionally, MCN has regularly collaborated with other NTTAPs that have a focus on agricultural workers through the Farmworker Health Network to address diabetes (FHN; see sidebar). Yet other vulnerable populations beyond migrant and seasonal agricultural workers struggle with diabetes as well. AAPCHO (Association of Asian Pacific Community Health Organizations) focuses on Asian American and Native Hawaiian and other Pacific Islander populations, of which there are numerous subpopulations with unique health needs and risks. AAPCHO began its work on diabetes in the early 2000s, when the World Health Organization first reported the high prevalence of diabetes among AA and NH/PI communities and issued a call to action.
“The diabetes outcomes are really out there in terms of uncontrolled diabetes,” noted Albert Ayson, Jr., MPH, Associate Director of Training and Technical Assistance for AAPCHO. One way that AAPCHO is working with health centers on diabetes is to encourage the screening of Asian Americans at a body-mass index of 23, instead of 25, to better meet the needs of Asian Americans who may have different body morphology and require the adjusted screening. Ayson said AAPCHO is working closely with Pacific Islander communities to determine which screening methods are better for that population. “’Asian American’ is not a monolith,” he said, and appropriate screenings must be developed accordingly.
Like MCN and AAPCHO, many of the NTTAPs had already provided training and technical assistance around diabetes related to their subpopulations. When the HRSA priority on diabetes was announced in 2017, AAPCHO and MCN joined forces to bring all the NTTAPs together to build a Special and Vulnerable Populations Diabetes Task Force (henceforth referred to as the Diabetes Task Force), despite each group’s unique subpopulation foci, with the goal to provide clinicians with comprehensive in-depth diabetes content across diverse patient communities. “MCN and AAPCHO have coordinated this task force since it began – and they have done a fantastic job of not just bringing all of us together, but also having us become invested in the work,” said Alexis Guild, MPP, Director of Health Policy and Programs for Farmworker Justice.
Special and Vulnerable Populations Diabetes Task Force in Action
After initial meetings on collaboration, the nascent Diabetes Task Force set out to provide national webinars developed by a cross-section of the NTTAPs. Every year since, the Diabetes Task Force develops a National Learning Series, consisting of four webinars with a minimum of three NTTAPs that coordinate each of the webinars. Each webinar is followed up with a Learning Collaborative taking a deeper dive into the topic at hand, and from there a relevant resource compendium is developed.
“It’s been a very thoughtful process in terms of how we engage health centers, and we’ve reached a huge number of people,” said Jillian Hopewell, MPA, Director of Education and Communication for MCN. “We look at diabetes care from individual, community, and systemic points, and it’s very multidisciplinary.”
Additionally, the NTTAPs have fortified relationships among each other, allowing for greater collaboration and for cleaner and more thorough offerings to clinicians. Instead of five webinars about diabetes, offered from five different organizations, which may duplicate some information or encourage a clinician to pick and choose, the Diabetes Task Force lays out a holistic approach covering multiple populations that a clinician is likely to encounter, and efficiently providing training to serve those populations. “I thought it would be a saturation of diabetes training and technical assistance opportunities, but working together has helped our community health center audience to navigate the learning opportunities, since we can have them fit together – less to parse through, easier to navigate,” said Emily Grace Kane, MPA, Senior Program Manager at the National Nurse-Led Care Consortium (NNCC). The working relationships also allowed for easier collaboration on other technical assistance and training efforts, both funded by HRSA and outside of HRSA, added Guild. Critically, it has encouraged NTTAPs focused on different populations to find common ground. “There’s a lot in common… [and] similar challenges across populations, and similar strategies that are successful across populations,” Guild noted. “What’s great about the Task Force is that because we work together, these silos have broken down.”
In the first four years of webinars, the Diabetes Task Force has covered numerous topics. Broader topics like the popular “Heath Center Strategies for Diabetes Screening and Prevention for Children, Adults, and the Elderly” were followed by population-specific webinars like, “Housing Instability and Diabetes Outcomes in Agricultural Workers and LGBT Communities.” Each of the NTTAPs participated and collaborated as speakers and experts.
In 2020/2021, the Diabetes Task Force presented Diabetes Continuum of Care, with four webinars on bridging the health literacy gap to improve diabetes outcomes; increasing patient technology and digital health literacy; raising the pillars for community engagement; and building successful teams during the COVID-19 pandemic. The recorded webinars, accompanied by slides and resources, are archived on the Diabetes Task Force website: https://chcdiabetes.org/nls. Continuing education credits are also available.
The offerings continued to be popular in 2020, despite the pandemic shifting foci for most health care providers. “Diabetes has not been the priority this year – it’s been COVID,” admitted Kane. “We as the Task Force have talked more about being a group of technical assistance organizations who provide guidance around all kinds of chronic conditions as they relate to special populations.” The group recognizes that the close relationships they have built across organizations through the Diabetes Task Force will lead to better trainings and technical assistance in the future as well. “The trainings we do are agnostic in terms of the disease states we talk about. They cross comorbidities,” Kane added. “The topics are always evolving, but the need for technical assistance to address those challenges is going to be the same.”
For 2021/2022, the Diabetes Task Force will shift gears operationally as AAPCHO and MCN reduce their national coordination roles and other NTTAPs step in to provide that coordination role, which reflects the ongoing highly collaborative element of the project. This year’s topics will be announced on the Diabetes Task Force website, www.chcdiabetes.org.
Resources
Visit the Diabetes Task Force website: www.chcdiabetes.org
Download MCN’s Spanish-language low-literacy diabetes comic book, Mi salud es mi tesoro: una guia para vivir bien con diabetes (My Health is my Treasure: A Guide for Living Well with Diabetes): https://bit.ly/3crhAJr
REFERENCES
1 Diabetes: A Snapshot: Diabetes in the United States. Centers for Disease Control and Prevention. Accessed 12 August 2021. Available at: https://www.cdc.gov/diabetes/library/socialmedia/infographics/diabetes.html
2 National Health Center Program Uniform Data System (UDS) Awardee Data. Health Resources & Services Administration. Accessed 12 August 2021. Available at: https://data.hrsa.gov/tools/data-reporting/program-data/national
3 Diabetes and Hispanic Americans. US Department of Health and Human Services, Office of Minority Health. Accessed 12 August 2021. Available at: https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=63
4 Montgomery MP, Kamel F, Saldana TM, Alavanja MC, Sandler DP. Incident diabetes and pesticide exposure among licensed pesticide applicators: Agricultural Health Study, 1993-2003. Am J Epidemiol. 2008;167(10):1235-1246. doi:10.1093/aje/kwn028
Read this article in the Summer 2021 issue of Streamline here!
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