ABSTRACT
STATEMENT OF PROBLEM/QUESTION: Improve diabetes quality and equity during the pandemic. DESCRIPTION OF PROGRAM/INTERVENTION: Elmhurst hospital center is one of 11 acute care hospitals in the NYC H+H network, the largest public health care system in the United States. Elmhurst hospital was at the epicenter of the COVID 19 pandemic in March 2020;providing care for immigrant, uninsured and underinsured patients, including more than 5000 patients with diabetes. As NYC emerged from the first surge, the primary care clinic assessed and addressed care gaps. Difficulties in accessing in-person visits, lab, and the social and economic impact on patients added to the challenges of managing diabetes during the pandemic. Disproportionately burdened were ethnic and racial minorities. An assessment of the diabetes outcome revealed that the control rate of diabetes defined as Hemoglobin A1c (A1c) less than 8% dropped by 8% compared to the pre-pandemic rate. There was a 4% difference in diabetes outcomes between the insured and uninsured patient populations.The clinic leadership implemented a collaborative care model. The collaborative care model consists of clinical pharmacists, registered nurses, a diabetes education-certified dietitian, and the population health team that provides outreach and data analytics support. Patients referred to the collaborative team by the primary care provider who assists in setting the treatment plan and goals. The collaborative care team screens every patient for barriers and social needs, provides diet education and a self-management plan. Each patient receives medication management in either the RN led treat-totarget clinic or by the clinical pharmacist. The referral criteria follow an algorithm based on the A1c level of control, number of medications, and the use of injectables. Cases are discussed weekly in collaboration with the primary care provider. The level of care is adjusted to address patient needs. The team determines the number of visits and time between visits based on the clinical progress. Visits are conducted in person and virtually;tailored to the patient's ability to use telehealth. MEASURES OF SUCCESS: Diabetes control improved by 10% in 8 months. The gap between insured and uninsured was reduced from 4% to 1% at the end of the study project period. FINDINGS TO DATE: A team-based approach using risk stratification that incorporates clinical outcomes and patient social barriers led to significant improvement in diabetes outcomes and closed the inequity gap. KEY LESSONS FOR DISSEMINATION: - High-quality diabetes care requires a multi-disciplinary team approach. - Treat-to-target RN visits improved access and equity in diabetes care. - Clinical Risk algorithms must incorporate social barriers. - Team-based approaches require continuous training and evaluation, with team members empowered for decision making.