Jon Liebman, M.S., M.S.N., and Dawn Heffernan, M.S.N.
Holyoke Health Center (HHC) in Holyoke, Massachusetts, has two sites that serve about 20,000 patients, most of whom are Spanish speaking. More than 1,700 of the adult patients have diabetes. In 1999, HHC adopted an electronic registry to track these patients and their clinical data. In 2003, HHC began using the data registry to identify patients lost to routine follow-up or who were in poor glycemic control and at risk for adverse outcomes.
Team members included primary care providers, a primary nurse, a pharmacist, a diabetes educator, a nutritionist, and medical assistants. In 2003, trained community health workers were added to the diabetes care team to engage and support patients who were not succeeding in managing their diabetes.
Adults in poor diabetes control were targeted by community health workers for phone outreach and, as needed, home visits, to assist them to reestablish primary medical care. The health workers functioned as a link between patients and their physician and other team members to help resolve problems and assist patients in overcoming barriers to implementing diabetes self-care behaviors.
In addition to team meetings and telephone contact, the team members communicate through formalized documentation tools in the medical record, including progress notes, in-house referrals, and shared Excel spreadsheets to outline the current services and community health worker assignments.
The initial project, Proyecto Vida Saludable, was funded by the Robert Wood Johnson Foundation. Other funders have included the Health Resources and Services Administration, Massachusetts Department of Public Health, Massachusetts Association for the Blind, Blue Cross Blue Shield, and Massachusetts Medical Society.
Improvement in two key indicators may partially reflect the effects of the interventions. First, the proportion of patients with diabetes who had been seen within the previous three years but who had not had an appointment within the previous year was reduced from 28 percent to 6.5 percent. Second, over three years the average A1C was reduced from 8.4 percent to 7.5 percent, and the proportion of patients with an A1C >10 percent decreased from 18.2 percent to 10.8 percent.