Developing a Patient-Care Team Co management Model for Diabetes Management 

Fiona McCaughan

Diabetes is a major contributor to disabilities: cardiovascular disease, blindness, kidney failure and lower limb amputation.  In Massachusetts more than 7% of adults have diabetes, and Black, non-Hispanic; Hispanic and Asians have a higher prevelance of diabetes.  One of our strategic initiaitves at Cambridge Health Alliance is to improve the health of our patients, specifically to improve the percentage of patients who have controlled diabetes.  We use careplans with our patients to partner in their health by engaging patients around what is important to them and their overall well-being.  We know that engaged patients are more likely to understand their health needs and treatments  and we use the careplan as a platform for this.  This project will work with patients and care providers to evaluate the care plan process from both the patients' and the providers' perspective and using one care team to try various interventions to improve the process and outcomes.