Improving Diabetes Care and Outcomes on the South Side of Chicago

• HbA1c [ Time Frame: Baseline data will be collected at the end of 1st year; follow-up data will be collected at the end of year 2, year 3, year 4 and year 5 ] [ Designated as safety issue: No ]
  Chart audit will be conducted on 100 randomly selected diabetes patients meeting the age inclusion criteria (age 18 years and older)
  
  
• Blood pressure [ Time Frame: Baseline data will be collected at the end of 1st year; follow-up data will be collected at the end of year 2, year 3, year 4 and year 5 ] [ Designated as safety issue: No ]
  Chart audit will be conducted on 100 randomly selected diabetes patients meeting the age inclusion criteria (age 18 years and older)
  
  
• Lipids (HDL, LDL, total cholesterol, triglycerides) [ Time Frame: Baseline data will be collected at the end of 1st year; follow-up data will be collected at the end of year 2, year 3, year 4 and year 5 ] [ Designated as safety issue: No ]
  Chart audit will be conducted on 100 randomly selected diabetes patients meeting the age inclusion criteria (age 18 years and older)
  
  

• comprehensive diabetes care [ Time Frame: Baseline data will be collected at the end of 1st year; follow-up data will be collected at the end of year 2, year 3, year 4 and year 5 ] [ Designated as safety issue: No ]
  Chart audit will be conducted on 100 randomly selected diabetes patients meeting the age inclusion criteria (age 18 years and older)
  
  

The approach we will use includes:

1. Culturally tailored patient activation training classes providing education and communication strategies to empower patients to be proactive in their diabetes self-management behavior.
2. Provider cultural competency and communication training to aid in tailoring treatment recommendations to the patient's cultural preferences and readiness.
3. Team-designed quality improvement projects to improve care for diabetes patients. QI projects will follow the plan-do-study-act methodology, be supported by experts from the field, and be provided additional resources. Collaborative community partnerships with organizations such as Kennedy King College and the Little Black Pearl will support individual QI projects.
4. Patient advocates and participating health centers will link patients to local resources such as the Washington Park Consortium and Regency Home Health Care to facilitate increased care management.
5. In addition, we will identify the costs of intervention implementation from the business case perspective of the outpatient clinics and determine the major barriers and solutions to successfully implement this multifaceted intervention.