Community Health Center Inc.: A Model of Collaboration Helps People With Diabetes to Succeed

Publication Date:

Publisher:

Author(s): Diabetes Initiative

Research Area: Health

Type: Report

Abstract:

At the Meriden, New Britain and Middletown clinics of Community Health Center (CHC) in Connecticut, collaboration among the primary care physicians, psychologists and certified diabetes educators has been the key to successful diabetes management and care. Each practice site serves a population of predominantly indigent, uninsured or underinsured patients from ethnically diverse backgrounds.
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CHC's Advancing Diabetes Self-Management project, a culturally sensitive diabetes education project, enrolls patients on a referral basis. During intake evaluations, certified diabetes educators collect baseline clinical information; review informed consent forms; perform an individualized assessment focusing on diabetes knowledge, as well as psychosocial, cultural and social factors; and administer a depression screening questionnaire. Patients with coexistent depression are referred for a collaborative behavioral health intervention with a therapist for counseling and treatment and connection to local support groups.
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CHC's education intervention allows participants to set specific self-management goals and connect to resources to help accomplish them. For example, an overweight Hispanic woman who recently arrived from Puerto Rico was struggling to manage her diabetes. She weighed 262 pounds and wanted to learn to speak English. Her team of collaborators enrolled her in an English class where she made new friends, began walking and lost 30 pounds within months—a major step toward managing her diabetes.
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Key Accomplishments:
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* Integration of behavioral health services into the diabetes self-management project
* Expansion of the role of staff nurses to review and facilitate participants' self-management goals
* Development of a tool to track—on a scale of one to four—both the setting and accomplishment of self-management goals
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Key Lessons:
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* Self-management must be tailored to patients' specific needs, provided in different formats and integrated into primary care.
* Optimal diabetes self-management includes depression screening and options for addressing a range of negative emotions.
* Successfully integrating the concept of self-management goal-setting requires ongoing training and support for both providers and patients.