Diabetes Collaborative

In response to the overwhelming needs for comprehensive diabetic care in underserved and predominantly minority populations, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Near North Health Services Corporation and Erie Family Health Centers have embarked on a comprehensive strategy to help diabetic patients living in underserved areas. We have developed and implemented a patient-centered, cost-effective care program that helps patients better self-manage their diabetes.

The goal of the program is to help patients become more educated about their diabetic disease and manage it according to the best standard of care. Our diabetic model of care has been expanded to two federally-qualified health centers.

The Diabetes Collaborative draws upon each organization's areas of expertise.

• Northwestern Memorial contributes expertise in diabetes care, health communication and patient education through our Health Learning Centers and provides critical funding for staff to organize and manage activities carried out through the program
• The Feinberg School of Medicine contributes the expertise of its nationally-recognized Program in Communication and Medicine, which addresses effective communications with patients
• Near North and Erie bring their collective experience in providing community-based care to their predominantly African-American and Hispanic patients

We have had many successes and outcomes, including:

• Decreasing blood sugar levels (an indicator of how well a patient is managing his or her diabetes)
• Helping patients achieve their self-management goals (which help patients manage their diabetes)
• Increasing staff to better manage patients and help achieve the goals of the Diabetes Collaborative
• Establishing a Chronic Care Team to help patients reach their goals
• Evaluating barriers of access to care and establishment of protocols/policies to address barriers
• Receiving recognition of the Diabetes Collaborative by Mutual of America Awards Foundation (2009)

We also offer equipment and services that make serving patients easier, including:

• An electronic medical records system to track and manage patients more efficiently
• Seven culturally sensitive, bi-lingual (Spanish and English) education and health-literacy appropriate patient education videos
• Two visual field machines that are essential in the diagnosis and treatment of glaucoma-a preventable disease that can lead to blindness if not treated

To date, more than 2,300 patients with Type II Diabetes have been tracked through Near North's diabetic registry, and nearly 500 patients from Erie's Humboldt Park location have accessed the program. There are plans to implement the program at Erie's other health centers in the near future.