Transforming diabetes care in an underserved Asian population: Best practices in translating evidence-based interventions into practice in a community health center

Background: Studies of diabetes in Asian Americans is limited, but data suggest diabetes prevalence is two to four times greater among Asian Americans compared to non-Hispanic whites. In addition, most diabetes management interventions have not been tested in an underserved, immigrant, low-income Asian population. For Federally Qualified Health Centers (FQHCs), the problem is compounded by limited resources with which to address this growing problem. Methods: A literature review of evidence-based interventions and best practices revealed that panel management and health coaching are promising, cost-effective models for diabetes management. Using the Chronic Care Model and Model for Improvement, we implemented a hybrid panel management/health coaching program. The implementation workgroup included doctors, a nurse practitioner, an RN, IT staff a health educator, clinical pharmacist, and an administrator to ensure a culturally relevant intervention tailored to clinic culture and patient needs. Results: 3 MAs split 1 FTE health coaching/panel management position to support 6 provider's diabetic panels. At the end of 2011 there were 633 patients in the diabetes registry: annual HbA1c testing rates had increased 12.6% (p=.001), LDL testing rates increased 12.6% (p<.01), eye exam testing rates increased 75.4% (p<.0001). Preliminary results indicate an increase in glucose control (HbA1c<7). Conclusions: Implementation of a hybrid panel management/health coaching model shows promise for improving diabetic care in FQHCs serving a low-income, underserved, immigrant Asian population. Key personnel reflect upon lessons learned, best practice recommendations.