Special Edition: Diabetes

HRSA BPHC Primary Health Care Digest

November 14, 2018

Special Edition: Diabetes

Photo Submitted by Southcentral Foundation in Anchorage, Alaska. Read their promising practice below.

November is National Diabetes Awareness Month, and today is World Diabetes Day. It has been over a year since the Health Center Program launched the Diabetes Quality Improvement (QI) Initiative and the first special edition on diabetes. Today’s special edition highlights efforts to date on the part of HRSA, health centers, and our technical assistance and training partners to improve diabetes control and health outcomes for health center patients, which include:

  • Diabetes Quality Improvement Webpage: provides health centers with information about the initiative, promising practices, and resources to improve the quality of their diabetes programs.
  • Health Center Resource Clearinghousehighlights diabetes as a priority topic and has an up-to-date selection of current, high-quality resources about diabetes prevention, screening, and treatment with a focus on special and vulnerable populations. The clearinghouse provides an archive of resources that were developed by health center TA and training partners as part of the diabetes QI initiative in 2018.
  • Diabetes QI focus during Operational Site Visits: reviews performance on the diabetes control measure, conducts root cause analysis, and generates health center action plans with goals and activities for diabetes QI and recommendations for further technical assistance. For more information, view the Site Visit Protocol and the Five Tips for a Successful Operational Site Visit Video.

In general, health centers have a higher prevalence of patients with diabetes at almost 15%1 when compared to the U.S. population at nearly 10%.2 Although health centers, on average, exceed national benchmarks in diabetes control, we have not moved the needle on diabetes control in the past few years. Poorly controlled diabetes can lead to multiple complications, poor health outcomes, reduced quality of life, and increased health care costs. Diabetes disproportionately impacts racial and ethnic minorities. The management of patients with diabetes, like other chronic conditions requires proactive care that addresses the medical, social, and behavioral aspects of individuals.

[1] 2017 UDS
[2] 2016 National Committee for Quality Assurance

Percent of Health Center Patients with Uncontrolled Diabetes by Race/Ethnicity 

Racial and ethnic disparities persist in health center patients with uncontrolled diabetes (A1C >9%)

Source: 2016-2017 Uniform Data System (UDS)
Note: Uncontrolled diabetes is defined as A1C > 9%

Lessons Learned in Diabetes Management

From interviews with health centers and project officers, health centers that are performing well in the diabetes control measure engage in certain core activities, including:

  • Ensuring complete and accurate documentation in the electronic health record to capture, in structured fields, data for the diabetes control and weight screening measures, foot and eye exams, and other relevant diabetes care information;
  • Using patient data to develop a diabetes registry and gap list, identifying patients who need guideline-based tests and procedures or other specialized care;
  • Following up with patients who are due or overdue for guideline-based care;
  • Establishing a personalized diabetes management or action plan for each patient with pre-diabetes or a diabetes diagnosis;
  • Providing education and support to patients and their families on lifestyle modifications and adherence tools, with the support of multidisciplinary team members, such as diabetes health educators, nurses, dieticians, community health workers, or clinical pharmacists;
  • Addressing social risk factors by establishing partnerships with community based organizations, such as food pantries, farmers markets, and fitness programs.

Promising Practices

Here are some examples of innovative approaches health centers and a Primary Care Association are using to help patients prevent or control diabetes. Thank you to all of the organizations that shared their models. Please reach out to the contacts below to get more information. 

Share Our Selves, Costa Mesa, CA

  • Uses Medication Therapy Management (MTM) appointments, conducted by clinical pharmacists, to support patients with diabetes. 
  • MTM appointments help patients optimize medication lists, engage patients in medication management and lifestyle modifications, and decrease their risk of adverse medication events. 
  • Patients are encouraged to bring family members to these ongoing appointments to educate everyone in the household about the patient’s condition and how to achieve a healthier lifestyle.

Read the full promising practice.

Contact:  Dr. Mary Ann Huntsman, Director of Clinical Pharmacy Services 

Southcentral Foundation (SCF), Anchorage, AK

  • Created a diabetes registry and action list that captures the preventive, screening, and disease/condition status of each provider’s panel of diabetes patients. 
  • Data drives quick action: if a customer-owner (patient) is identified as being due for a test or exam, SCF reaches out to him/her and makes a quick intervention.
  • Community Health Aides provide care in remote areas; they are high school graduates who have received training to provide care by protocol, including diabetes management. Living and working in remote Alaskan communities, they are supported by distant site SCF physicians through telehealth.  
  • They follow up on the diabetes action lists with customer-owners in these locations, connecting them to specialty services using telehealth and coordinating health educator visits to these remote sites.

Read the full promising practice.

Contact: Brianne Gorham, M.A., Manager of HRSA grant (907)729-3250

Pennsylvania Association of Community Health Centers (PACHC)

  • Spearheaded an effort to train Pennsylvania health center staff in diabetes prevention using lifestyle coach training.
  • PACHC hosted a two-day training using the CDC lifestyle change curriculum. This program helps people who are at higher risk of developing diabetes adopt changes designed to reduce risk through measures such as diet and fitness.
  • Participants also learned about CDC’s National Diabetes Prevention Program, which aims to reduce patients’ risk of type 2 diabetes.
  • Participants were introduced to the Prevent Diabetes STAT toolkit and educational materials designed specifically for health care professionals by the CDC and the American Medical Association.
  • PACHC recruited training participants by using UDS data to identify health centers with higher rates of uncontrolled diabetes among their patients.

Read the full promising practice.

Contact: Serina Gaston, Director of Strategic Initiatives & Corporate Compliance 

Technical Assistance

Technical Assistance

Health Center Program Diabetes QI Initiative

Health Center Resource Clearinghouse

Request Technical Assistance

Technical Assistance Calendar

Health Center Program Leaders

Diabetes Prevention and Management Leaders


Advancing Oral and Primary Health Care Integration to Support Diabetes Prevention and Management
Thursday, November 29
1:00 p.m. – 2:00 p.m. ET
Register here

Leveraging Diabetes Prevention Programming for Your Health Center
Thursday, November 29
2:00 p.m. – 3:30 p.m. ET
Register here


CDC 2017 Diabetes Report Card provides current information on the status of diabetes in the United States.

2018 American Diabetes Association Standards of Medical Care in Diabetes

USPSTF Recommendations on Managing Obesity

FDA: Health Care Providers to Reduce Hypoglycemic Events in Patients with Type 2 Diabetes
Free, one-hour lecture; CE credit is available