Introduction and Objective: Type 2 diabetes (T2D) is a major public health challenge in the U.S., accounting for 90-95% of all diabetes cases. Individuals with A1C levels above 8% face increased risks of complications; however, diabetes self-management education (DSME) can effectively reduce A1C levels. Proactive DSME is essential for managing these patients. This retrospective analysis examines the impact of a Primary Care Population Health platform utilizing a Pull Model to refer patients with A1C levels >8% into an interdisciplinary DSME program in partnership with an Endocrine department, measuring pre- and post-outcome data within 12 mos.Methods: Eligible patients were aged 18-75 years with a diagnosis of T2D, A1C >8%, residing within the state. Exclusions included Type 1 diabetes, out-of-state residency, refusal to participate, and loss of follow-up and a patient within the healthcare system. The DSME program delivered patient-centered services through a team of CDCES, including dietitians, pharmacists, and nurses, over 12 months. Integration of DSME and patient tracking in a population health platform was implemented. A paired t-test compared A1C levels pre- and post-intervention, with pre-intervention values ranging from 8.5 to 13.2% and post-intervention values from 6.80 to 8.20%.Results: Data from 348 participants were analyzed, yielding a mean age of 51 yrs. (SD = 14). The cohort included 52% female, 45% Caucasian, 22% Hispanic, 13% Asian, 7% Black, and 13% Other. The mean dif. in A1C levels was 1.83% (t-statistic = 5.07; p < 0.0005), indicating a significant reduction. Secondary findings showed a 97.4% attainment rate for self-directed DSME goals, 94% completion of diabetes-related tests within 12 mos., and an 84% increase in coordinated services (e.g., Nutrition, Pharmacy, and Endocrine).Conclusion: Leveraging population health platforms to offer A1C surveillance and engage participants in DSME effectively lowered A1C levels and improved patient outcomes, supporting similar strategies in diabetes management.
A. Simos: None. J. Ringrose: Employee; Insulet Corporation. M. Gabriel: None. S. Tsai: None. J. Hong: None. M. Basina: None.
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