Alliance to Reduce Disparities in Diabetes

Initiatives: The Diabetes Equity Project

The Diabetes Equity Project (DEP) in Dallas is transforming the Baylor Health System with the aim of reducing disparities in care for underserved people with diabetes in Dallas County, Texas. Accomplishments include:

Institutionalizing the Community Health Worker role within the Baylor Health System. The DEP was one of the first in the nation to establish new job codes for Community Health Workers within a large health care system.  The CHW role has been embedded into clinical care teams in 5 of 60 patient-centered medical home (PCMH) clinics.  Funding to sustain the CHW positions has been incorporated into clinic budgets. DEP has submitted a proposal to secure state Medicaid funding to expand and sustain services provided by CHWs.

Implementing a comprehensive diabetes registry (DiaWEB). A fully-implemented diabetes registry, DiaWeb, allows the DEP to monitor patient participation and track clinical outcomes. Data from the registry have been included in electronic medical records and patient charts. Program staff also implemented a series of uniform patient data collection protocols across 110 provider network clinics that helped to facilitate collection of race and ethnicity data.

Expanded use of Electronic Medical Records (EMR) to improve communication among team. CHWs are now able to document patient interaction and communicate with medical staff via electronic medical records.