Diabetes Management Intervention For South Asians

Diabetes Management Intervention For South Asians

The goal of this study is to evaluate the effectiveness and implementation process of a multi-level, integrated intervention to decrease HbA1c among South Asians with uncontrolled diabetes, including four components: 1) an EHR-based registry function to increase identification of South Asian patients with uncontrolled diabetes; 2) CHW-led health coaching of registered patients to promote health behavior change; 3) HIT-enabled and CHW-facilitated identification and referral to culturally relevant community resources for patients; and 4) HIT-enabled care coordination between the CHW and other members of the healthcare team.

Inclusion Criteria:

• South Asian ethnicity (identified through a race and language code available in the EHR);
• an appointment with a physician for routine non-emergent primary care in the last 12 months
• diagnosis of diabetes
• an HbA1c reading of >7 in the last 12 months

Exclusion Criteria:

• Pregnant women and visits to obstetrician/gynecologist are excluded from the study