Improving Diabetes Care and Outcomes on the South Side of Chicago

This multifactorial intervention contains four overlapping core components reflecting key
elements of the Chronic Care Model.This model identifies patients, practice teams, the
community, and health systems as four necessary elements in the successful management of
chronic diseases such as diabetes. Six health centers (two academic center clinics
affiliated with the University of Chicago and four FQHCs) are part of the intervention.
Researchers at the University of Chicago received grant funding from the Merck Company
Foundation's Alliance to Reduce Disparities in Diabetes and the National Institutes of
Health to implement and evaluate the intervention.

The research and implementation team includes faculty and staff members with expertise in
quality improvement, behavioral change, community outreach, patient education, and research
methods.

The intervention has four main components:

1. Patient Activation: We hold culturally tailored, 10-week patient education classes that
combine culturally tailored patient education with training in shared decision-making
skills to empower patients to be proactive in their diabetes self-management.

2. Provider Training: We provide educational workshops for provider, clinical, and
non-clinical staff at our six intervention clinics on patient-centered communication,
cultural competency, behavior change counseling, and shared decision making.

3. Quality Improvement: Our team facilitates quality improvement (QI) programs redesigning
clinic operations to improve care for diabetes patients. QI initiatives have included
instituting group visits, patient medication cards, peer support groups, flow sheets,
nurse case management, and patient registries. New initiatives include improving access
and tracking of specialists visits through EMR, employing community health
workers/patient navigators, coordinating care, and implementing other team-based care
initiatives. We also perform a cost/benefits analysis of intervention implementation
from the business case perspective of the outpatient clinics and determine the major
barriers and solutions to successfully implement and sustain the project at each
location.

4. Community Outreach: We collaborate with existing community resources to create
sustainable collaborations that support diabetes patients outside of the health care
system and promote nutrition and a healthy lifestyle. We collaborate with grocery
stores, food pantries, the Chicago Park District, farmers markets, media outlets,
grocery stores and other community-based organizations.

Inclusion Criteria:

- Patients must have a diabetes diagnosis (ICD-9 codes 250.X) and be age 18 years or
older

- Patients must attend one of the participating health centers

Exclusion Criteria:

- Gestational diabetes patients