Improving Diabetes Prevention and Management

Project Title

Chinatown Diabetes ACTION (Accelerating Collaboration To Improve Health Outcomes Now)

Grant Amount


Priority Area

Improving Diabetes Prevention and Management

Date Awarded

November 15, 2007







Diabetes is a growing epidemic. In New York, the prevalence rate is higher in Asian communities, particularly among adults born in South Asia.

With proper management, diabetes can be controlled; however, medically underserved and disadvantaged groups, such as Asian Americans, often have difficulty managing the disease. With support from NYHealth, Charles B. Wang Community Health Center (CBW) formed the Chinatown Diabetes Accelerating Collaboration to Improve Health Outcomes Now (ACTION) to further improve its care for its patients with diabetes. This initiative has allowed CBW to build a foundation for continued sustainability of diabetes management activities. This project was funded under NYHealth’s 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

One in six Asian Americans in New York City has diabetes, and an additional 3,300 Chinese patients in New York City are at risk for diabetes. This project furthered CBW’s effort to implement the chronic care model by establishing a diabetes registry and piloting a culturally appropriate diabetes self-management program.

CBW served approximately 1,300 diabetic patients and  identified more than 2,000 patients with prediabetes. CBW improved diabetes management for this population by creating a culturally competent model of care incorporating the Chronic Care Model and electronic medical records (EMR). NYHealth funding supported start-up costs for implementing comprehensive systems changes that will result in improved care and health outcomes for diabetic and patients with prediabetes. Specifically, CBW set out to:

  1. establish a diabetes registry in its existing EMR and develop tools and protocols to better track and manage patients utilizing EMR;
  2. pilot-test a diabetes self-management education program that makes use of bilingual group workshops and group visits; and
  3. assess organizational readiness for meeting the American Diabetes Association’s national standards for diabetes self-management education, which will enable the program to be sustainable through reimbursement.