The Diabetes Collaborative was created by the Bureau of Primary Health Care in 1999. The goal is to work with Community Health Agencies to improve the health of underserved populations and increase access to care. This is done by working with Community Health Agencies on specific chronic diseases (Diabetes, Cardiovascular Disease, Depression and Asthma). The Collaborative helps these agencies redesign their way of providing health care so patients are healthier and are able to self-manage their disease more effectively.

Our Diabetes Team at the Willimantic site is:

Team Member Name	Role/Title
Arvind Shaw, MBA	Senior Leader, Executive Director
Nestor Enrique Torres, MD	Physician Champion
Kari Davis, APRN	Team Leader – Day to day contact
Pat Pipitone, MA	PECS/Data Entry
Nancy Quimby, APRN	Clinical Technical Expertise
Deb Savoie, MBA	MIS Contact
Margaret Ann Smith, DDS	Dental Member

The aim of Generations Family Health Center is to redesign our data collection process and operationalize the Chronic Care Model into our Performance Improvement System which will allow us to affect change for our diabetic patients. In the future, we will apply this process to all diabetics in our health centers and to other disease processes. Specifically our initial aim will be to have documentation in 90% of our Diabetes Mellitus patients have two HbA1c (glucose levels) at least 3 months apart in 12 months and 70% of patients have a documented self-management goal reflected in the chart. In addition we would like to see a 10% decrease of the HbA1c (glucose levels) mean in all patients involved in our initial population of focus.

Our plan is to have all patients at the Willimantic site involved in the collaborative and then spread it to the remaining Generation sites at Norwich, Brooklyn and Danielson. Our current Key Measures are:

Required Measures	Goal
1. Average HbA1c	£ 7.0 %
2. Patients with 2 HbA1c’s in last year (at least 3 months apart)	> 90 %
3. Documentation of self-management goal setting	> 70 %
4. Patients Age > 40 on Statins (cholesterol lowering medication)	> 50 %
5. Patients with BP < 130/80	> 40 %
6. Patients with Dental Exam	70 %
Additional Recommended Measures Selected
Patients with LDL < 100	70 %
Patients with Foot Exam	90 %

Yearly screenings for Diabetic Patients include:

· Fasting Cholesterol Blood work

· Dilated Eye Exam

· Foot Check

· Dental Exam

· Flu Shot

· Urine test

· HbA1c (glucose levels) blood test

With good blood sugar control patients with Diabetes will be able to prevent further damage such as numbness, tingling in legs and arms, heart attacks, dental disease, eye disease, loss of kidney function and loss of sexual function. These tests help you and your health care provider manage your disease and monitor your progress.

Signs and symptoms of Diabetes include:

· Increased Thirst

· Increased Urination

· Unexplained weight loss

· Dizziness or confusion

People at an increased risk of developing diabetes are:

· People with relatives that have the disease

· Being Overweight

· Hispanic or African American Heritage

Other links that may be of interest to learn more about Diabetes, how to prevent it and how to better manage it are:

www.ctpca.org

www.diabetes.org

www.cdc.gov/health/diabetes

If you have further questions please feel free to email us at diabetesgen@wcmh.org .

This information is not meant to be used for personal medical advice. If you have specific personal health questions you should contact your medical provider.