Ending Type 2 Diabetes One Exercise, Nutrition, and Gardening Class at a Time

Where Diabetes Prevention Began at FHCHC: from Individual to Systematic Care Models PART I

In About the Program on August 11, 2010 at 6:12 PM

“25 years ago, the occasional adult had diabetes. Then something interesting happened. Ask any family provider in this country today, and they will report that around 15 years ago, numbers of prediabetic and diabetic patients increased dramatically.” Elizabeth, one of the family nurse practitioners responsible for starting the Fair Haven Community Health Center’s Diabetes Prevention Program, describes the diabetes screenings’ evolution. “There was just no denying the onslaught of diabetic and prediabetic symptoms.”

The other providers at the Fair Haven Community Health Center also began to notice the sharp incline of patients with diabetic and prediabetic symptoms. Together they launched a proverbial offensive. Using American Diabetes Association guidelines, they regularly initiated one on one conversations with their at-risk patients, organized a diabetes education group, and created management tools like diabetes flow sheets and occasions to jointly review charts.

Soon, however, providers began to notice that the breadth of their offensive was disproportionate to the growth of the disease. One initiative, the Breakfast Club, is a perfect example of this inequity. Elizabeth met with diabetic patients 2-3 mornings per week. Over a diabetes-appropriate breakfast, they would talk about nutrition, lifestyle, exercise, and all the other circumstances that impacted their health. The program was extremely successful while in session. As soon as there was a break or lapse in meetings, however, Elizabeth’s patients’ numbers would shoot right back up again. Self management was one of the systemic gaps in diabetes prevention and care that the providers felt the need to fill once their preliminary offensive was launched.

The provider’s collective insight into the next required level of diabetes care came the same year that the Institute for Healthcare Improvement teamed up with the Bureau of Primary Health Care to enlist all community health centers nationwide in Health Disparities Collaboratives (HDCs). (Click here for a comprehensive report on the evolution of HDCs). The Fair Haven Community Health Center received a number of benefits for participating in this healthcare improvement project, the most revolutionary being an online patient registry. In 1995 within a short period of time, providers had the ability to create lists from the entire patient population based on predetermined criteria. They could cull all patients with a family history of diabetes, or see all patients diagnosed with acanthuses. Providers were also able to see, on one sheet of paper, an overview of patients’ chronic conditions. (Click here to view a sample chronic care encounter form). The possibilities for data collection and group action were endless, and what was at first an individualized offensive on diabetes became a collaborative and systematic campaign.


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