Alliance to Reduce Disparities in Diabetes

Initiatives: South Side of Chicago

The University of Chicago is working in six clinics on the South side of Chicago to implement comprehensive clinic and health system redesign by:

Integrating Community Health Workers and Care Coordinators into the clinical care team. The Chicago group is working to institutionalize the role of Community Health Worker/Care Coordinator within the six clinics. Care coordinators will play a critical role in patient navigation, education and liaison between the community and clinic. Job roles have been established and agreed upon and funding to sustain the position is underway. The group is seeking a grant from the Illinois Medicaid program to help sustain the positions.

Instituting diabetes group clinic visits. New group visits or shared medical appointments are being implemented at several of the South side clinics. Many patients prefer group visits because they are generally longer than traditional doctor-patient visits, allowing more opportunities for patients to talk with their health care provider, ask questions and share experiences with other patients. This change required several related changes in clinic policies such as requiring patients to sign HIPAA-compliant patient confidentiality agreements, revise billing procedures and the clinic handbook on policies and procedures.

Establishing a diabetes registry to track high-risk patients.  Diabetes rosters or registries or being developed to help track high-risk patients at several clinic sites. All clinics have now implemented electronic health records and are working to develop a shared system that will allow for greater data sharing capabilities.

Setting up formal agreements with community partners. The University of Chicago has established strong community partners to help sustain healthy patient behaviors outside the clinic. Formal agreements are underway with the local park district and community centers to offer free gym memberships to diabetes patients and with grocery stores to offer gift cards and store tours with nutrition education provided by the research team.