Whittier Street Health Center

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Diabetes Care Coordination Program

Location: Boston, Massachusetts

African-American women who met diabetes self-management goals were trained as Diabetes Health Ambassadors to identify and refer women in their public housing projects to Whittier Street Health Center’s comprehensive diabetes care services. More than 900 women were connected to diabetes screening and 312 women were engaged in care at the clinic.  For the women for whom pre and post assessment data were available, there were statistically significant improvements in average HbA1c, blood pressure and weight.


Whittier Street Health Center (WSHC) is a Federally Qualified Health Center (FQHC) located in the Roxbury neighborhood of Boston, Massachusetts.  This project aimed to identify African-American women with Type 2 diabetes living in public housing developments in Roxbury and engage them in comprehensive diabetes care services offered by Whittier Street Health Center.  Public housing residents living in Roxbury are three times more likely to have diabetes than other Boston area residents and have the second highest diabetes-related hospitalization rate in the city and surroundings.  Whittier Street Health Center offers free primary care and preventive health services and for many in Roxbury it is the only source of accessible and culturally-appropriate health care.


Diabetes Health Ambassadors, women themselves living in public housing developments, diagnosed and successfully controlling their diabetes, were the essential link between public housing residents and Whittier Street Health Center.  The Diabetes Health Ambassadors provided on-site health screenings and diabetes education workshops in the public housing developments.  Once women with diabetes were identified, they were referred to care at Whittier Street Health Center.  As part of Whittier’s comprehensive diabetes care program, the women were connected to a patient navigator to coordinate their care and received diabetes self-management education by an ADA-certified diabetes educator, diabetes group medical visits with social support and access to clinical care, and a diabetes clinic providing access to a variety of diabetes care related services.


  • Using culturally-competent Diabetes Health Ambassadors from public housing led to increased access to the public housing residents, increased visibility within the community, and built trust. Using this approach, more than 600 women were connected to diabetes screening and care.
  • African-American women act as gatekeepers for health to their families and serving one woman means serving the whole family. Lifestyle changes made by participants may have had an impact on other family members living within the home. “It takes a village”, in this case a comprehensive, coordinated clinical team to provide the needed services for controlling diabetes.
  • Diabetes Health Ambassadors gained new insights into the management of their own disease and adopted additional lifestyle changes that improved their personal health and well-being.