Last January, Community Health System launched a 12-month pilot program aimed at reducing diabetes cases in the Valley. It was rolled out to over 300 Community employees with the eventual goal to introduce it to other Valley patients.
How it works: When a patient in the program goes to the emergency room for a diabetes-related issue, a registered nurse (RN) navigator reviews their chart to evaluate the patient's recent care, how well they take their medication and any missed screenings or lab work. Typically within 48 hours of leaving the hospital, the RN navigator will connect with the patient to assess current needs, reinforce discharge instructions and schedule any necessary follow-up appointments.
A tailored support plan is developed. This can include:
- Ongoing phone check-ins for medication coaching, symptom monitoring and appointment adherence
- Coordination with the primary care provider to ensure timely follow-up visits
- Lab and screening review to close preventive care gaps such as A1c (blood sugar level test), eye exams or foot checks
- Education and self-management support, particularly around blood glucose control, diet and lifestyle
Why it matters: The program is highly collaborative with primary care providers. It’s part of Community’s effort to prioritize preventive care — i.e., keeping patients healthy and reducing the need for emergency services.
Diabetes is one of the most prevalent conditions in the Central Valley. In Fresno County, the rate is 13%, which is 2% higher than California’s.
The condition is considered an “entryway” to other health issues, including:
- Heart disease
- Stroke
- Kidney problems
- Eye problems
- Amputation
“We’re excited about what this program could mean for patients in the Valley with diabetes,” said Dr. Christopher Kuebrich, family medicine physician with Community Primary Care. “Prevention is critical when it comes to managing chronic illness and cutting down on unnecessary complications.”
Diabetes care at Community:
- Our Diabetes Education Center offers on-demand education and resources for diabetes management and is available to all Community patients.
- The Diabetes Self-Management Education and Support program is an assessment and training program that covers nutritional management, medication, self-monitoring blood glucose and more.
