New York State Health Foundation

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Gold Choice PCMP IIA

  • Project Title: Improving Diabetes Outcomes in Behavioral Health Care Recipients
  • Priority Area: Diabetes Prevention and Management
  • Grant Amount: $317,863
  • Date Awarded: November 15, 2007
  • Region: Western New York
  • Website:
  • Grant Status: Complete


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. In January 2008, NYSHealth awarded Gold Choice a grant to develop 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. NYSHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

Grant Goals

Gold Choice set out to accomplish the following goals:

  • Deploy evidence-based American Diabetes Association (ADA) guidelines to primary care providers and patient support staff to improve the management of diabetes among its patients with mental illness and/or substance use conditions;
  • Use telephonic nurse case managers to enhance nurse case management, follow-up, and patient education to improve self-care measures among patients with diabetes; and
  • Use practice enhancement assistants to facilitate the implementation of preventive service guidelines.

Grant Outcomes

Gold Choice achieved the following outcomes:

  • Conducted quarterly practice-based chart reviews to generate individual patient reviews for primary care providers and telephonic nurse case managers;
  • Maintained a centralized database of core diabetes care elements, which was used to generate quarterly performance feedback reports on measures to promote practice improvement work;
  • Conducted a 12-month evaluation of the program, and noted an improvement in rates of HDL cholesterol levels; and
  • Noted a significant increase in aspirin prescriptions, a surge in the percentage of patients obtaining pneumococcal vaccines, and an increase in annual flu shots, which suggests that the program had a positive impact on physician adherence to ADA-recommended guidelines.

Grantee Information

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

Download Grant Outcomes Report