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Diabetes

Using Community Health Workers to Reduce Disparities

Using Community Health Workers to Reduce Disparities

Project


A community health worker, formally trained in diabetes management, is added to the health care team.

Project leaders in partnership with the Central Massachusetts Area Health Education Center adapted a nationally-recognized community health worker training program to include information on how to assist patients in their efforts …
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Redesigning Care Delivery in Fee-for-Service Practices

Redesigning Care Delivery in Fee-for-Service Practices

Project


Redesign the way diabetes care is delivered in a rural primary care practice.

Based on the Chronic Care Model, primary care practices are redesigned to include a “circuit rider” staffing method, in which a certified diabetes educator nurse, a dietitian and a certified diabetes educator phar…
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Personalized Diabetes Education and Coaching

Personalized Diabetes Education and Coaching

Project


Community-based diabetes coaches are incorporated into the care team.

Diabetes coaches, who themselves have type 2 diabetes, are recruited directly from the local community and trained to work one-on-one with patients who are identified using an existing electronic diabetes registry. The coaches share language and sociodemographic…
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Pay-for-Performance Programs to Improve Care

Pay-for-Performance Programs to Improve Care

Project


Health plan reaches out to enrollees and provides bonus payments to participating primary care providers for high-quality, patient-centered care.

Hudson sends members with diabetes a letter reminding them of the importance of an annual flu shot and enumerating the other key components of their diabetes care. Sometimes the letters …
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Patient Financial Incentives and Culturally Tailored Diabetes Outreach

Patient Financial Incentives and Culturally Tailored Diabetes Outreach

Project


Monetary incentives are directed at patients and coupled with culturally tailored outreach and education materials.

The incentives are based on improving HbA1c levels, and the schedule of incentives will incorporate several factors. Those factors include: frequent monitoring of HbA1c, payments for achieving small, manageable miles…
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Customizing Health Messages Based On Cultural Understanding of Disease

Customizing Health Messages Based On Cultural Understanding of Disease

Project

Community Health Educators make a series of eight, hour-long home visits over the course of nine months.

To prepare for the visits, Community Health Educators receive 12 hours of interactive, workshop-based training on semi-structured interviewing techniques to help better elicit a patient’s pers…
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Cultural Competency Training and Disparities Report Cards

Cultural Competency Training and Disparities Report Cards

Project

Providers receive cultural competency training and monthly race-stratified performance reports.

Over the course of 12 months, primary care physicians, nurse practitioners and physician assistants are given tools and training regarding racial disparities in health care. Participating clinicians attend lunchtime lectures that focus on racial disparities in the quality of diabetes care withi…
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