Improving Diabetes Prevention and Management

Grantee Name

Gold Choice, PCMP IIA

Funding Area

Improving Diabetes Prevention and Management

Publication Date

July 2013

Grant Amount


Grant Date:

January 1, 2008 – March 3, 2010


Gold Choice is a behavioral health Medicaid managed care program serving Erie County.

Approximately 450 Gold Choice patients who receive care through 60 Erie County primary care sites are currently diagnosed with diabetes. These individuals are especially vulnerable to diabetes-related complications, as their behavioral health conditions often affect their ability to adhere to medication and self-care regimens.

In January 2008, NYHealth awarded Gold Choice a grant to develop a program to enhance care and improve outcomes for patients with both diabetes and serious mental illness and/or substance use problems. The program was designed to (1) use practice enhancement assistants to provide clinical information support to primary care practices serving Gold Choice patients with diabetes and (2) use telephonic nurse care managers to work specifically with this target population. NYHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

Outcomes and Lessons Learned

  • Conducted quarterly practice-based chart reviews to generate individual patient reviews for primary care providers and telephonic nurse case managers;
  • Maintained a centralized database of core diabetes care elements, which was used to generate quarterly performance feedback reports on measures to promote practice improvement work;
  • Conducted a 12-month evaluation of the program, and noted an improvement in rates of HDL cholesterol levels; and
  • Noted a significant increase in aspirin prescriptions, a surge in the percentage of patients obtaining pneumococcal vaccines, and an increase in annual flu shots, which suggests that the program had a positive impact on physician adherence to ADA-recommended guidelines.

Read the report associated with this grant,”Setting the Standard: A Foundation Initiative to Advance Best Practices in Diabetes Management.”