As part of the DLI, four state demonstration projects are working to detect and address the complications associated with diabetes. These projects are underway and provide invaluable insights on how early health system interventions can help people with diabetes who are at risk for complications, and provide them with appropriate strategies to help them manage their risk. Each state project focuses on two complications: diabetic kidney disease (DKD) and an additional complication based on needs of the individuals served by participating health systems.

For more information about the activities in each state, hover your cursor over one of the four states in the map below.

Michigan

The Michigan project is working with Henry Ford Health System in Detroit, MI, a major health system, and the Center for Family Health in Jackson, MI, a federally qualified healthcare center, which both offer diabetes self-management education (DSME) programs. The primary intervention strategy focuses on integrating an assessment for DKD and retinopathy in the DSME one-on-one assessment conducted by a diabetes educator. Additionally, for patients with stage 3 or 4 DKD, staff is providing educational materials and communicating with the primary healthcare provider about referrals to nephrologists and medical nutrition therapy, as needed. Finally, staff is performing phone follow-up to measure patient knowledge and behavior change as a result of these efforts.

To date, the project has worked with 24 health care providers and reached over 3,100 people living with diabetes.

Contact Richard Wimberley, MPA, the Michigan DLI Program Director, for more information.

New York

The New York project is working with Hudson River HealthCare (HRHC), a community health center network, in Spring Valley and Yonkers to develop and implement a curriculum focused on diabetes complications, including diabetic kidney disease (DKD) and the importance of foot examinations. Project strategies include training community health workers to deliver the curriculum to educate people with diabetes, conducting diabetes community education days and holding webinars for educating healthcare providers.

In addition, information generated by an electronic database is being used to identify and contact people with stage 3 or stage 4 DKD and encourage them to attend a diabetes self-management education (DSME) program. Global alerts in the health center's electronic health record are being used to increase the healthcare team's awareness of services that may be needed as a result of a patient's DKD or neuropathy. The system is also tracking the percentage of patients with diabetes who received an annual foot exam.

To date, the project has worked with 12 health care providers and reached over 1,100 people living with diabetes.

Contact Laura Shea, RN, MA, the New York DLI Program Director, for more information.

North Carolina

The North Carolina project is working with three community health centers (New Hanover Community Health Center, Blue Ridge Community Health Services and Gateway Community Health Center) and two free clinics (New Hope Free Clinic and Cape Fear Free Clinic) to increase diabetes patient participation in medical nutrition therapy and diabetes self-management education (DSME) programs. The project is focusing on updating the DSME curriculum to adequately address diabetes complications, including DKD and high blood pressure, and the community health centers are tracking quality of care and health outcomes for people with diabetes. Additionally, the program aims to improve access to community resources and increase the number of referrals from physicians to educational programs. Primary care physicians are encouraged to refer patients to nephrologists as needed.

To date, the project has worked with 37 health care providers and reached over 1,700 people living with diabetes.

Contact April Reese, MPH, CPH, the North Carolina DLI Program Director, for more information.

Wisconsin

The Wisconsin project is working with three clinics within the Wisconsin Research and Education Network to improve quality of clinical care related to DKD and cardiovascular disease. They are using tools to increase awareness and education of DKD and high blood pressure in order to improve self-management strategies among people with diabetes. The program aims to support healthcare providers in helping their patients understand test results and to increase engagement to slow the progression of diabetes complications.

To date, the project has worked with six health care providers and reached over 500 people living with diabetes.

Contact Liz Grinnell, the Wisconsin DLI Program Director, for more information.

As part of the Diabetes Leadership Initiative, the National Association of Chronic Disease Directors developed the following materials for professionals working to serve people with diabetes:

White Papers


Additional Resources and Fact Sheets