Developing and Implementing a Primary Care Model for Low-Income Retired Patients with Diabetes

Improving Diabetes Prevention and Management

Grantee Name

UNITE HERE Health Center

Funding Area

Improving Diabetes Prevention and Management

Publication Date

September 2013

Grant Amount

$460,042

Grant Date:

January 1, 2008 – August 26, 2009

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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).

Outcomes and Lessons Learned

Developed a training curriculum and a multidisciplinary tool to aid staff members in individualizing treatment goals for patients with both uncontrolled diabetes and multiple chronic conditions;
Enhanced the role of its on-site pharmacist, incorporating the pharmacist into the care team;
Developed a plan to support practice change that included staff member training; staff member skills assessment; design and implementation of customized diabetes education curricula; workflow redesign; development of electronic medical record templates to support new staff member functions and teamwork; and measures and evaluation activities to assess progress toward program goals and clinical impact;
Enrolled approximately 700 patients into Bridge Care (70% of its projected goal of 1,000 enrolled patients);
Trained 14 patient care assistants and 6 health coaches;
Developed two primary care medical home teams; and
Demonstrated improvements in the average score of all three clinical indicators of controlled diabetes

Read the report associated with this grant, “Setting the Standard: A Foundation Initiative to Advance Best Practices in Diabetes Management.”

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