Improving Diabetes Prevention and Management

Project Title

Development & Implementation of an Innovative Primary Care Model for Low Income Retired Patients with Diabetes

Grant Amount


Priority Area

Improving Diabetes Prevention and Management

Date Awarded

November 15, 2007







The UNITE HERE Health Center (UHC) provides health care services to enrolled union members in the greater New York metropolitan area. UHC developed and implemented a special care center for its patients, which was based on a primary care model designed specifically to improve the care of patients with chronic conditions and that relies heavily on patient care assistants. While health coaching services performed by patient care assistants are typically not covered under traditional plans, UNITE HERE active union workers are reimbursed through a special capitated arrangement. These services are not reimbursed for retired workers who are covered under traditional fee-for-service insurance. In 2008, NYHealth awarded UNITE HERE Health Center a grant to expand its service delivery model to its older patients with diabetes and address these coverage limitations. This project was funded under NYHealth’s 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals (RFP).

The center estimates that nearly 90% of its older retired patients with diabetes have also been diagnosed with heart disease or hypertension and are therefore at higher risk for worse disease outcomes. UHC will develop a new curriculum to train patient care assistants regarding the special needs of the elderly, with a focus on geriatric syndromes that affect care of elderly diabetic patients, including multiple medications, depression, and cognitive impairment. Retired members will receive primary care services and personalized attention from patient care assistants, who will help them set self-management goals and provide telephone follow-up to monitor progress. UHC will evaluate this project in two ways:

  1. a process evaluation of the staff training on chronic disease management in elderly populations; and
  2. an outcomes evaluation of clinical markers including control of A1C, blood pressure, and cholesterol and access to regular foot and ophthalmology exams.