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

Health workers, physicians and nurses collaborated to implement an innovative model using clinic-based planned visits with health workers to provide 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 having poorly controlled diabetes, having fallen out of care or having failed to follow through on recommended screening services. Using an electronic diabetes registry, bimonthly queries enabled health workers to track targeted patients and call them in for planned visits. In addition, providers referred patients who fit criteria to schedule planned visits with health workers. Target goals and measures were developed which evaluated clinical outcomes on a monthly basis. Patient clinical outcomes were tracked and compared between those patients receiving and not receiving planned visits. A service model was implemented which consisted of individual planned visits with the health worker two weeks prior to a provider appointment. Each planned visit included: a monofilament foot exam; an eye exam referral if indicated, a blood pressure check, a lab draw, medication reconciliation, appropriate immunizations and a discussion of behavioral changes by setting culturally appropriate self management goals. Health workers also made referrals for nutritional counseling, group medical visits and healthy living classes as indicated. This presentation will discuss the process used to implement this service model and will provide information on how interested agencies can replicate this model.