Online Program

Innovations in prediabetes care: A collaboration of the AMA, Y and Family medicine practices

Tuesday, November 3, 2015 : 1:10 p.m. - 1:30 p.m.

Michael Rosenthal, MD, Department of Family and Community Medicine, Christiana Care Health System, Wilmington, DE
Omar Khan, MD, MHS, FAAFP, Primary Care & Community Medicine, Christiana Care Health System, Wilmington, DE
Margot Savoy, MD, MPH, FAAFP, Department of Family & Community Medicine, Christiana Care Health System, Wilmington, DE
Karen Anthony, MS, CHES, Department of Family & Community Medicine, Christiana Care Health System, Wilmington, DE
Janet Williams, MA, Illinois Coalition Against Tobacco, Chicago, IL
Prediabetes represents an important contribution to diabetes disease burden in the US. Pre-diabetes education and support programs have been demonstrated to reduce the risk of developing diabetes and complications of the disease, but current medical payment models do not reimburse for pre-diabetes counseling.

A pilot group of medical practices referred their patients with prediabetes to a community based program offered by the Y.  Patients who were Medicare-eligible and had lab values indicating prediabetes were referred to a local YMCA.  The YMCA provided a CDC-approved, standardized year-long educational program which included information on healthier eating, physical activity and other behavior changes. 

The AMA provided practice support, provider education and a linkage between the local efforts of the YMCA and practices, and national-level coordination.   Christiana Care Health System, one of the largest in the country, participated in this effort through the Family Medicine faculty/resident practice. 

We will describe the method of patient identification and referral, to include as many eligible patients as possible without adding to provider and staff burden.  We will also present data on the number of patients referred and those who actually followed up.  Preliminary results indicate this is a viable model to identify and treat individuals with prediabetes via provider involvement and coordinated linkage to community-based health education programs.  By presentation time, clinical data on effectiveness should also be available.

Learning Areas:

Administer health education strategies, interventions and programs
Chronic disease management and prevention
Clinical medicine applied in public health
Implementation of health education strategies, interventions and programs

Learning Objectives:
Describe Christiana Care's Prediabetes Initiative Explain the steps to creating a prediabetes screening and referral process Discuss opportunities to increase prediabetes testing and referral in a health system

Keyword(s): Primary Care, Diabetes

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: As CCHS Department of Family & Community Medicine Medical Director I was responsible for the implementation of the Pre-diabetes project which will be presented. I have direct clinical experience caring for patients with pre-diabetes/diabetes, teach at a national, state and local level on topics including obesity, prediabetes/diabetes and am the primary care lead for our Primary Care and Community Medicine Diabetes Clinical Care pathway.
Any relevant financial relationships? Yes

Name of Organization Clinical/Research Area Type of relationship
American Academy of Family Physicians Obesity, Clinical Preventive Services Commission on Health of the Public & Science member and subcommittee chair and Speaker's bureau and teaching engagements
Christiana Care Quality Partners Quality Improvement Committee Advisory Committee/Board
Highmark Delaware Health Equity Committee Health Equity Committee Advisory Committee/Board
Christiana Care Health System family medicine Clinical leader for Diabetes Clinical Care Pathway and Employment (includes retainer)

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.