Chelsea Diabetes Management Program

The Diabetes Management Program serves the unique needs of patients at MGH Chelsea through case management, coaching, diabetes self-management education, and support groups.

In addition to the challenges all diabetes patients face in managing a complex disease, minority patients and those of lower socio-economic status often face additional challenges due to language barriers, cultural and socioeconomic factors, and poorer access to high quality care.

A 2005 assessment conducted at MGH Chelsea determined that disparities existed in diabetes control and monitoring between Latinos and whites in Chelsea. In response, the Diabetes Management Program was created in 2006 as an interdisciplinary, culturally sensitive model to serve the unique needs of patients at MGH Chelsea, The program is a collaboration of CCHI, MGH Chelsea, the Disparities Solutions Center, and the Mass General Physicians’ Organization (MGPO), and comprises four core program components:

     • Identifying and following pateints in the Adult Medicine practice who have poorly controlled diabetes, defined by blood   sugar lab results of HbA1C of 9 percent or above:

     • Coaching using a culturally competent model for chronic disease management that emphasizes working with patients to explore their barriers to achieving good diabetes control and developing a plan to help them overcome these barriers;

     • Teaching patients how to regularly test their blood sugar in keeping with clinical recommendations, and helping patients to obtain glucometer devices and supplies

  • Diabetes self-management education (DSME) involving nurse educators, dietitians, physical therapists, and mental health professionals, provided in group or individual visits in both English and Spanish.

This combination of approaches, including addressing barriers to care and management with home visits, phone communication, and accompanying patients to appointments, has shown success in diabetes management. In 2011 662 coaching sessions were conducted for 236 patients. 699 patients have received coaching services since the program’s inception in 2006. 

Also in 2011, there was an average decrease of 1.36 in HbA1c between the last test taken before the pateints began meeting with the diabetes coach (average=9.7) and the most recent test results available (average=8.3) (n=120). For those with HbA1c equal to or above 9.0, there was an average decrease of 2.57(n=64) (from an average of 11.8 to 9.2).

Luz Betancourt

Phone: 617 887-3789
Email: lbetancourt@partners.org