Glucose to Goal: A Model to Support Diabetes Management in Primary Care

Evidence that diabetes self-management education (DSME) can improve health outcomes has
repeatedly been shown and is considered to be a critical component of care. Diabetes
educators are highly skilled at addressing diabetes-related clinical and behavioral needs
through DSME, but engagement with diabetes educators is underutilized. It has been suggested
that poor referral practices and the way in which DSME service is delivered are the problems.
Most patients receive diabetes care in primary care yet most DSME programs are distinctly
separate from primary care practice. This limits care coordination and diabetes educator
access to amenities currently available to primary care. Efforts are underway to change the
US health care paradigm with a focus on quality in primary care that includes practice
redesign, population management, and communication through electronic medical records. The
purpose of this application is to evaluate the deployment of Glucose to Goal, a model relying
on a systematic redesign of practice that links diabetes educators services with primary
care. This will be compared to the traditional process for DSME delivery, without the direct
connection to primary care processes, for an eighteen month period. The hypothesis is that
the proportion of primary care provider referrals and patient utilization of diabetes
educator services from primary care practices participating in Glucose to Goal will be higher
compared to those associated with traditional DSME. It is anticipated that this model will
appeal to primary care providers, demonstrate a feasible approach to offering diabetes
education in the current health environment, and set the stage for future testing of the
model, namely its impact on meaningful improvements on diabetes outcomes and
cost-effectiveness.

Inclusion Criteria:

- Clinical diagnosis of type 2 diabetes

- Patients referred to diabetes self-management education by their primary care provider

- Able to read and write English

Exclusion Criteria:

- Clinical diagnosis of type 1 or gestational diabetes

- Unable to speak or read English