Duke University Medical Center

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The Durham Diabetes Coalition

Location: Durham County, North Carolina

The Durham Diabetes Coalition is committed to improving population-level health outcomes and quality of life for adults suffering from type 2 diabetes and at the same time sought to reduce disparities in health outcomes. Through a specially enabled informatics system, visual maps revealed disproportion in the prevalence of diabetes among Durham County residents. Through this innovative system, patients of high need were identified and interventions were then implemented to meet the specific needs of patients. Using data from Duke University Health System, 14,345 unique patients were identified. A risk algorithm was used to distribute patients into low, moderate, or high-risk groups and guide the appropriate interventions in combination with recommendations from providers. During the Together on Diabetes project period, the informatics system allowed for real-time monitoring of individuals and populations with type diabetes, allowing for data-driven decision-making.


To meet the needs of patients with diabetes, Duke University developed a program for Durham County residents. The diabetes program had four goals to: 1) Improve population-level management, health outcomes, and quality of life for diagnosed and undiagnosed adults living with type 2 diabetes; 2) Reduce disparities in diabetes management, health outcomes, and quality of life for adults living with diabetes; 3) Implement a countywide, community-based, population-level suite of interventions that is sustainable and replicable in other American communities; and 4) Build effective spatially-enabled informatics systems that support the development and implementation of the interventions and allow for real-time monitoring and evaluation.


To address the many challenges in Durham County, the Durham Diabetes Coalition and community partners developed a multilevel intervention to address barriers to diabetes care and make changes to the social and physical environment. First, the team connected patients to a primary care provider and a support group that included other people experiencing the same health concerns and related barriers. Second, patients were linked to community resources to assist with transportation, health insurance application, disability process, diabetes testing supplies, and meal programs. Third, clinical services were also provided to patients with diabetes. Those included: 1) Diabetes self-management education; 2) Self-monitoring blood glucose; 3) Diabetes medication adherence education and support; and 4) Prevention of diabetes complications. Additionally, patients received additional support such as the reminders to increase medication adherence. Lastly, behavioral support was provided through: 1) Positive reinforcement; 2) Smoking cessation classes, 3) Behavioral therapy, 4) Medical nutrition therapy, and 5) Referrals to psychiatry.


Key learnings from the project include:

  • Developing the risk algorithm that places patients into low, moderate, or high-risk groups and guides interventions for patients in conjunction with recommendations from providers allowed for tailoring the intervention based on patient needs.
  • Willingness to be innovative and think outside the box to implement a range of interventions for high, moderate, and low risk diabetes patients.
  • Meeting people “where they are” (e.g., home, community buildings, church, salons, parks, etc.) and being receptive to different viewpoints was important in assuring continued participation.
  • On-going communications and group meetings with health care, informatics, and public health staff as well as community partners, patients living with diabetes, and project leadership allowed for new and modified intervention components.
  • A marvelous community advisory board and strong collaborative partnerships allowed for data-driven and community-driven interventions.