Improving Diabetes Prevention and Management

Grantee Name

Seton Health System

Funding Area

Improving Diabetes Prevention and Management

Publication Date

September 2013

Grant Amount


Grant Date:

January 7, 2008 – April 28, 2010


Seton Health is part of Ascension Health system, which serves a large swath of poverty-stricken areas in northeastern New York characterized by higher-than-average levels of poverty, vacant housing, and female-led households, and low levels of education.

Diabetes disproportionately affects low-income populations, which have much higher rates of diabetes-related complications and mortality. In 2008, NYHealth awarded Seton Health a grant to use an established parish community nurse model and its outpatient diabetes education program to create its Defy Diabetes initiative and address the needs of people with diabetes. NYHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

Grant Goals

Seton Health set out to accomplish the following goals:

  • Reach 1,000 people through Seton Health’s Faith Community Parish Nurse Program through health fairs, church talks, and health living classes;
  • Improve new patients’ self-care, including management of weight, blood pressure, cholesterol, and blood sugar levels;
  • Engage 25 primary practices to increase compliance with the American Diabetes Association (ADA) guidelines; and
  • Develop a Web-based system and data collection tool to track progress and outcomes.

Outcomes and Lessons Learned

Seton Health achieved the following outcomes:

  • Held 18 pulpit talks and 18 health fairs and printed announcements in church bulletins and mailings in 6 interfaith communities;
  • Trained 16 parish nurses and 2 community health workers to implement the Defy Diabetes healthy living classes at their houses of worship, reaching 193 people;
  • Identified and recruited 14 nurse champions to help their primary care providers improve their practices by following ADA guidelines for diabetes care and submitting data for National Committee for Quality Assurance (NCQA) diabetes recognition;
  • Purchased SharePoint software to collect data that would give feedback to providers;
  • Conducted trainings with nurse champions for 32 primary care sites to introduce them to diabetes quality improvement practices; and
  • Submitted 10 NCQA applications, which led to 7 practices receiving recognition.

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