Colorado University: EPiC-4DM

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Location: Denver, Colorado Metropolitan area

The EPiC-4DM Project aimed to address the large health disparity among minority populations with Type 2 Diabetes, Depression, and Diabetes distress in Denver, Colorado. Through collaboration with various community partners, a practice level intervention was created and tailored to meet the specific needs of the six federally qualified health centers (FQHCs) involved in the EPiC-4DM project. This project focused on patient centered care by: a) utilizing the 5A model to create individualized action plans for diabetes management and b) creating a 3-way linkage among patients, practices, and community based programs and resources to improve outcomes relating to diabetes self-management, diabetes distress, and depression.


The EPiC-4DM project goals were to improve diabetes self-management, mental and physical health, and the experience of health care for patients. The intervention was focused on underserved adult patients with Type 2 diabetes cared for by the Metro Community Provider Network (MCPN); a network of FQHC that spans Denver, Aurora, and Jefferson County. Patients served by MCPN are nearly 3x more likely to have diabetes (14.23%) than in the state overall (5.9%), and 2x more likely to have diabetes than in Denver overall (7.0%).


The intervention focused on four components, which led to 169 accomplishments across the six sites throughout the duration of the project. The four main components were: 1) Diabetes self-management education, 2) Modifying access, barriers, and opportunities related to diabetes care, 3) Enhancing services and supports related to diabetes care, and 4) Modifying policies and broader systems for those with diabetes.


Key lessons from this project included:

  • Engaging community partners in the creation of the intervention was key in determining the specific needs of the community and its members.
  • Integrating behavioral health leadership and patient navigators led to improved project implementation and provided additional patient support in creating individualized self-management action plans.