Dr. Martin Luther King, Jr. Health Center

Dr. Martin Luther King, Jr. Health Center (MLK) serves a predominantly vulnerable population of more than 668,300 people in the central and south Bronx.

Diabetes has reached epidemic proportions among these residents, with 11% to 17% of adults reporting having diabetes—a rate that is significantly higher than the overall New York City rate of 9% and the national goal of under 2.5%. Uncontrolled diabetes contributes to a number of health complications: increased risk for heart disease and stroke, end-stage renal disease, blindness, and amputations. In January 2008, NYHealth awarded MLK a grant to standardize diabetes care across its ambulatory care clinics’ internal and family medicine departments, integrate community health workers (CHWs) into its treatment plan for patients with diabetes, and reduce diabetes-related complications. NYHealth funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.

The Dr. Martin Luther King, Jr. Health Center expanded its existing diabetes management program in internal medicine from 2 of its sites to 12 additional sites, and made the program the standard of care across all 14 practices in its network. The health center conducted trainings on the Chronic Care Model, Community Health Worker Model, and guidelines for diabetes care. By involving residents in this training, the health center fostered long-term adoption of these practices. A key component of the initiative was a diabetes patient registry, which was to be accessible to providers at all sites and used to track program and patient-specific outcomes. Diabetes teams at each of the clinics—comprising physicians, nurses, residents and administrative personnel—championed the effort and oversaw its implementation. In one family medicine clinic, an existing diabetes management program was paired with a community health worker program to test how the two programs can work together to affect patient outcomes. Community health workers provided peer support for patients with diabetes, educating them in self-management and helping them to take an active role in their health.