A collaborative, multidisciplinary, cost effective public health model for comprehensive service delivery to low income, multicultural diabetic patients receiving primary care from a large urban public health department

Lisa A. Golden, MD, Elizabeth Johnson, MD, Donna Baird Rice, LCSW, Greta H. Cheng, RD, CDE, Linda Woo-Lim, RN, NP, and Jane Ka-Wai Lam, BSc, MCS. Ocean Park Health Center, San Francisco Public Health Department, 1351 24th Avenue, San Francisco, CA 94122, 415-682-1917, lisa_golden@sfgh.org

A public health physician, nutritionist and medical social worker collaborated to implement an innovative, multilingual model for providing comprehensive, cost effective diabetic care to a patient population characterized by minimal health literacy, limited English proficiency, co-morbid medical and mental health diagnoses and different cultural attitudes toward health and illness. In addition, the initial target population was identified as newly diagnosed diabetic patients, patients who demonstrated a poor understanding of their disease process and/or poorly controlled diabetic patients. Target goals and measures were developed which were evaluated for each patient at three-month intervals. A service model was implemented which consisted of monthly group sessions. Each group session included: group sharing; an informational presentation which was culturally appropriate and understandable to a population with minimal health literacy; blood pressure measurements; review of labs, review of blood glucose levels, a provider visit; medication adjustments; a nutritionist discussion; and a closing summary including formation of action plans and opportunities for questions and answers. This presentation will discuss the process used to implement this service model and will provide information on how interested agencies can replicate this model.

Learning Objectives: At the close of this session, the participant will be able to

Presenting author's disclosure statement:
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: I am employed by the San Francisco Public Health Department