Improving Diabetes Prevention and Management

Project Title

Initiating a Diabetes Management Program for Underserved Populations

Grant Amount


Priority Area

Improving Diabetes Prevention and Management

Date Awarded

November 15, 2007







Jamaica Hospital Medical Center (JHMC) and Flushing Hospital Medical Center (FHMC) sites serve patients who are predominantly African American, Hispanic, and Asian and disproportionately affected by diabetes. These sites are located in neighborhoods that have higher-than-average mortality rates for diabetes—40.9 per 100,000, compared to 23.3 in all of New York City and 20.5 in New York State. In 2008, NYHealth awarded JHMC  a grant to develop a partnership with FHMC to address these disparities among its client base by implementing the Chronic Care Model (CCM) at its facilities. NYHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

Working in collaboration the Flushing Hospital Medical Center, Jamaica Hospital Medical Center, and the Neighborhood Health Plan (a Medicaid Managed Care Organization) implemented elements of the Chronic Care Model to improve diabetes treatment for 500 patients (enrolled in the Neighborhood Health Plan) in four ambulatory care sites in Queens and Brooklyn, including Family Care Centers at St. Albans, East New York, Richmond Hill, and Flushing Hospital Ambulatory Care Clinic. At these sites, physicians and residents  trained on the Chronic Care Model and the American Diabetes Association’s national guidelines. As part of the project, sub-specialists were made available on-site for visits, and diabetes health educators provided patient education, allowing one-stop shopping appointments for patients with diabetes. A centralized patient registry was adopted, and at one site, a community health worker program was piloted to observe and assist patients who need to control their diabetes in their home environments. The project used outcomes data to promote changes in reimbursement over time.