American Association of Diabetes Educators

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Implementing a Coordinated Care Model: A 12-Month Pilot

Locations: Jacksonville, Florida; Athens, Ohio; Oklahoma City, Oklahoma; Nashville, Tennessee

As the leading professional association for diabetes educators, the American Association of Diabetes Educators was interested in exploring the role of the diabetes health educator within a patient-centered medical home model. This project implemented an integrated model for treating patients with diabetes that required a patient-centered medical home and diabetes self-management education delivered by community health workers at four sites. The four sites that were selected to implement the model served representative groups of underserved diabetes patients including African-Americans and low-income residents of Appalachia. Among the notable features of the model were at-home or at-work follow-up care for patients who missed scheduled medical appointments; follow-up phone calls by health coaches to review and promote self-management behaviors; and providing transportation to treatment appointments. The intervention documented a decrease in HbA1c levels and improvements in LDL cholesterol, average blood pressure and average total cholesterol. Patients also reported gains in healthy coping and problem solving.


This project sought to integrate multi-level diabetes self-management education teams that included community health workers within four Patient-Centered Medical Homes (PCMHs).  Each implementation site provided care to a unique group of underserved patients, including African Americans and low-income residents of Appalachia.


The AADE coordinated care model implemented at the four sites featured three main components:

a) Comprehensive, multi-level diabetes self-management education program
b) Patient Centered Medical Home designation
c) Programs to address the needs of underserved populations

AADE staff worked with the four provider sites to ensure implementation of core components across the diverse sites. Although implementation of project components varied to reflect differences among sites—for instance, whether research or practice based—all sites provided DSME within a PCMH and engaged patient supporters to reinforce curriculum instruction and provide individualized support. Patient supporters included community health workers, AmeriCorps volunteers and Medical Assistants who were trained to share culturally relevant diabetes information and DSME support.


This project targeted underserved populations with type 2 diabetes to assess the feasibility of implementing a comprehensive model that integrates DSME within PCMH. Key learnings from this project include:

  • Integrating DSME with the PCMH model is a promising strategy for serving patients from diverse populations experiencing health disparities.
  • Patient supporters can deliver DSME and personal support for diabetes patients within these settings, an important contributor to patient satisfaction.
  • It is possible to provide quality DSME in the PCMH whether the two programs are already established or when DSME is newly integrated into an existing PCMH.
  • Policy changes and programs developed as a part of the initiative continue to be implemented after the funding concluded. This suggests that primary care providers and/or institutions find value in this integrated approach to addressing type 2 diabetes.