Stopping Diabetes in its Tracks (SDIT): Integrating a Hospital, Clinic, and Community Based Program for Type 2 Diabetes Prevention and Control

Stopping Diabetes in Its Tracks (SDIT) is an integrated set of community, clinic, and hospital interventions to prevent and control type 2 diabetes in Pomona. The model is designed to be replicable, scalable, and sustainable. CTRI is collaborating in this three-year project with partners in clinical institutions (i.e., Pomona Valley Hospital Medical Center, Pomona Valley Health Center), academic institutions (e.g., Claremont Graduate University, the University of Southern California, Western University of Health Sciences), and community organizations (e.g., the Pomona Unified School District, religious institutions). Heluna Health provides administrative infrastructure for a translational research grant from the UniHealth Foundation and SDIT collaborators. 

Accountable Community for Health in Pomona

An Accountable Community for Health is a multi-payor, multi-sector alliance of the major health care systems, providers, and health plans, along with public health, key community and social service organizations, schools, and other partners servicing a particular geographic area. An ACH is responsible for improving the health of an entire community, with particular attention to achieving greater health equity among its residents. The goals of an ACH are to (1) improve community-wide health outcomes and reduce disparities with regard to particular chronic diseases; (2) reduce costs associated with the health care and, potentially, non-health sectors; and (3) through a self-sustaining Wellness Fund, develop financing mechanisms to sustain the ACH and provide ongoing investments in prevention and other system-wide efforts to improve population health. With support from the California Accountable Community for Health Initiative (CACHI), CTRI is working with the many collaborators in the Pomona’s Promise initiative to transform it into an ACH. 

Riverside County Veterans Health Survey

To assess veterans’ unmet health needs and knowledge, utilization, and satisfaction with local and VA resources, CTRI surveyed >1,500 veterans in Riverside County, CA in 2018, from all military branches, decades of service, gender, and ethnicities; distributions represented current active duty personnel and the local adult population.


Many veterans had never used VA health (35%), education (37%), or home mortgage (42%) benefits. While 80% were satisfied or very satisfied with Riverside County Department of Veterans’ Services, only 40% had ever accessed any and more than one-third were unaware of them. Though chronic disease prevalence increased with age, emotional distress was greatest in those under 40 years old: 60-80% with high levels, 13% having contemplated suicide, 27% unemployed, 20% with household income of <$20,000, and 13% live in unstable housing conditions.


Veterans reported diabetes, heart disease, and hypertension at rates higher than the adult population. Poor access to preventive, health management, and social resources contributes to veterans’ disproportionate health burden. Policy changes should focus on emotional distress and upstream economic, unemployment, and housing issues for younger veterans.

A Population Health Approach to Primary and Secondary Prevention of Adolescent Emotional Distress and Self-Destructive Behavior

In response to an alarming increase in adolescent depression and suicide in the Corona-Norco Unified School District, CTRI is working with CNUSD leadership to institute a community-wide, population health approach to primary and secondary suicide prevention. We are collaborating with a variety of partner organizations, including the local Riverside University Health System Community Health Center and area universities (i.e., Claremont Graduate University School of Community & Global Health and Division of Behavioral & Organizational Sciences, University of Southern California Suzanne Dworak-Peck School of Social Work, and the Western University of Health Sciences Graduate School of Nursing). 

Development of a Population Health Roadmap

Population health can be defined as the health outcomes of a clearly demarcated group of individuals (a defined population) and its subpopulations, including the distribution of such outcomes within the population or subpopulation. Many but not all populations exist within recognized communities that may share common geographic boundaries, identities, and/or functional relationships among constituents.

CTRI developed a Roadmap for Population Health for the County of Riverside after obtaining feedback from the Riverside University Health System, department heads, other key County personnel, community leaders, and academic experts. The Roadmap 1) articulated the dimensions of population health relative to County services, 2) addressed population health as a concern that requires integration across non-RUHS as well as RUHS services, 3) pointed to the need for private sector as well as public sector involvement to achieve optimal population health outcomes with efficiencies achieved for both sectors through collaboration, 4) suggested specific assessment and programmatic steps for evidence-based population health to be undertaken in the near future, and 5) provided milestones for population health development in years to come.

The Roadmap recommended that measurable population health goals should be identified, prioritized, and planned for (strategy) with consideration of all relevant systems both internal to the county and external as necessary to achieve the population goals identified (systems), and system resources utilized in a transdisciplinary team approach (integration) adhering to sound scientific principles (systematic control and comparison based on sound data) to guide population health policy and practice.


Diabetes Free Riverside (DeFeR)

County public health officials rely on national surveillance systems to understand rates of diabetes, and thereby direct appropriate resources to communities. CDC reported that in 2013, 9% of the population in the County of Riverside were diagnosed with diabetes. However, extrapolations from The National Health and Nutrition Examination Survey (NHANES) physical examination data to Riverside County population characteristics, and later confirmed by direct A1C screenings in Riverside communities, indicated the actual diabetes rate to be approximately 19%, twice that reported by CDC. Through a collective effort, CTRI and the Riverside University Health System pilot tested a systems approach to community-based screenings and risk-intervention called Diabetes Free Riverside (DeFeR). DeFeR identified persons at high risk for diabetes in community settings and implemented an enhanced version of the National Diabetes Prevention Program (NDPP) to prevent or delay progression from prediabetes to type 2 diabetes. Carried out in low-income neighborhoods of two predominantly Hispanic cities, DeFeR demonstrated that well-organized community-based screenings can be uniquely useful to identify and engage in preventive interventions persons at high risk for diabetes. Results suggest that innovations to address social support, physical activity, and self-monitoring can optimize retention rates and health outcomes in communities with similar characteristics. Innovations that proved promising include the use of technology such as physical activity trackers, text-messaging, and virtual NDPP sessions. Finally, a systematic referral to county and private clinics for care for previously undetected individuals with diabetes can help streamline individuals to coordinated care.