Improving Diabetes Prevention and Management

Project Title

Improving Diabetes Outcomes in Behavioral Health Care Recipients

Grant Amount


Priority Area

Improving Diabetes Prevention and Management

Date Awarded

November 15, 2007


Western NY





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. To address these needs, Gold Choice developed 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. The New York Health Foundation funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

People with mental illness are especially vulnerable to complications from diabetes, as their condition often affects their ability to adhere to medication and self-care regimens. This project will establish diabetes registries, use nurse telephone case management and employ practice enhancement assistants to improve care for people with diabetes and mental illness.

One full-time and one part-time practice enhancement assistant will serve as temporary staff members and will be a shared resource for the 60 practices that provide care to Gold Choice members. Each practice enhancement assistant will help create diabetes registries and enter patient information into a computerized Diabetes Work Tool that includes check-boxes consistent with American Diabetes Association Guidelines. Based on that data, reports will be generated that inform nurses and physicians of recommendations for needed care and follow-up. Quarterly reports will be provided to physicians showing progress on practice change milestones. These reports will allow physicians to compare their performance to the other 59 participating practices. The assistants will also train office staff on using the computerized tool to allow for sustainability of the quality feedback reports over time.