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Transforming Diabetes Care in a High-Risk Community

By Kimberly Mitchell | Friday, February 27, 2015

An underserved community in California is at high risk for diabetes, and a local clinic is redesigning its processes to identify and treat those at risk for complications related to diabetes to provide better access to care and reduce the spread of this condition. In the following blog post, Contra Costa Regional Medical Center diabetes educator, Yahya Abdolcader, BSN, RN-CDE, PHN, shares some of the reasons he is personally invested in the work he is doing in the community.


As a kid, I remember my father telling me about my grandfather’s last days. He said, “My father was not able to stand or walk. He was bedridden and my mother had to care for him 24/7. We didn’t know what he died of, but it was mostly likely that he had a stroke.” When I was 12 years old, my maternal grandfather, who had diabetes for more than 20 years, finally succumbed to the disease and died. 

Diabetes has affected me all of my life. Not only have I seen my family members suffer because of this disease, I have heard many accounts of those in our Vietnamese communities dying from infections related to amputations, strokes, and heart attacks. Based on my experience working as a registered nurse and certified diabetes educator, I believe these deaths are more than likely associated with complications from diabetes. Despite being an avid runner and health advocate, my genetics significantly increase my chances of receiving a diabetes diagnosis one day. My experiences have inspired me to dedicate my life and work to preventing and helping others with diabetes.

A report published by the American Diabetes Association in 2012 detailed the effects of diabetes on the US health care system. The report showed that 29.1 million Americans (or 9.3% of the population) have diabetes, and 86 million Americans age 20 and older have pre-diabetes. The cost of diabetes is $245 billion a year ($176 billion in direct medical costs and $69 billion in reduced productivity).

LEARN MORE: Leading Population Health Transformation, Feb. 22-24, 2017, in San Diego, California

As a diabetes educator for West County Health Center, an affiliate of Contra Costa Regional Medical Center, I work for an underserved community in Richmond, CA. I see the effects of diabetes first hand. Many of the people I see are debilitated with foot ulcers, toe amputations, visual impairment, or complications from strokes and heart attacks. Despite how common diabetes is in the community I am surprised how little most people seem to know about diabetes. When I ask, “What is diabetes?” the overwhelming answer is, “I don’t know.”

In an effort to reduce health disparities and increase access to quality health care, I am working with a team of doctors, nurses, and health care workers to redesign our clinic’s systems and processes. For the past five months, we have been working on a project to implement the Diabetes Mellitus Clinic Bundle (DMCB) which consists of:

  • A1c labs (average blood sugar) drawn at least twice a year or as needed
  • Urine microalbumin drawn yearly
  • Bun/Creatinine levels drawn yearly
  • Blood pressure check done yearly or as needed
  • Foot exam done yearly or as needed 
  • Eye exams done yearly or as needed
  • Identifying safe practices: 1) treating hypoglycemia; 2) sick day protocols; 3) dealing with hyperglycemia; 4) safe usage and disposal of insulin and needles
  • Appointments with dieticians and nurse educators for diabetes self-management support

Patients who attend the DMCB clinic are those identified as being at risk for complications related to diabetes. When patients arrive at our clinic, we review their diabetes labs with them. We evaluate them for any acute conditions (hypoglycemia, hyperglycemia, visual impairment) and give them a foot exam. In addition to their evaluation, we provide direct access to appointments with our ophthalmologists, nutritionists, diabetes educators, and podiatrists to ensure they are receiving quality care to prevent long-term health complications related to poor control of blood sugars. We track all DMCB patients in our databases and a nurse follows up with each patient to ensure they receive adequate care. This ensures we provide ongoing support to assist patients towards improved glucose control.

We are starting to see some positive results. For example, one of our patients had an average blood sugar in the low 300s. After two months in our program, we redrew her A1c and it came out between 6-7 (average 130-150). This is a drop of 4-5 A1c points and dramatically decreases her risk of having a stroke, heart attack, and microvascular complications associated with diabetes (UKPDS Study on Diabetes). With continuing ongoing support, we hope to maintain her blood sugar numbers and assist her with challenges that may affect her glucose control.

Our DMCB project has shown improvements in the number of patients completing their diabetes labs. We are currently in the process of taking what we’ve learned from our first project and spreading it to our family practice clinics at West County. For example, we are sharing the program training guidelines we’ve developed, which include details on how to conduct an orientation with nursing staff, teach the curriculum, conduct one-on-one coaching with nurses, and provide constructive feedback. We are also sharing the work we designed for each phase of clinic development to help staff and preceptors follow quality of care standard processes.

Without access to modern health care, my grandparents never received quality care to prevent complications from diabetes. They didn’t have the opportunity to learn from a certified diabetes educator. Getting their hemoglobin A1c checked or having regular foot exams were never options because they lived in underserved areas.

Now, however, others do not have to suffer the fate of my grandparents. By establishing quality programs and improving access to diabetes care, we can prevent the spread of diabetes and improve patient outcomes. Currently, we face a huge challenge since diabetes and pre-diabetes in America are so prevalent. By developing the DMBC clinic, we hope to prevent and control the spread of diabetes. Moreover, we aspire to give hope and create changes in attitudes toward health and wellness to help generations to come.

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