In 2023, 40 million people had diabetes and an additional 115 million people had prediabetes.1 In Ohio, this problem shows no signs of slowing where the age-adjusted rates of diagnosed diabetes has been increasing over time.1
Further, in the United States, diabetes is the primary cause of blindness, lower-limb amputation, and kidney failure, and is currently the 7th leading cause of death.1
In the Northeast Ohio region, diabetes is a common problem, with prevalence rates ranging from 8% to 12% of the population.2 Between 2022 and 2024, the age-adjusted diabetes death rate in Northeast Ohio was 22.5 per 100,000 people.2 Using data from partner clinics participating in the Northeast Ohio Quality Improvement Hub (NEO QI Hub), hemoglobin A1C (A1C) levels ≥ 9% were estimated in the 20% to 30% range, demonstrating an opportunity for improvement. Additionally, the majority of Northeast Ohio counties experience primary care shortages, with 88% designated as Health Professional Shortage Areas (HSPAs) by the Health Resources and Services Administration (HRSA).3
The Ohio Department of Medicaid, in collaboration with academic leaders, health care providers, and payers, has established Regional Quality Improvement (QI) Hubs across Ohio to advance population health improvement for Medicaid enrollees. The NEO QI Hub is led by Case Western Reserve University (CWRU) School of Medicine in partnership with Northeast Ohio Medical University (NEOMED), regional health care systems, and Federally Qualified Health Centers (FQHC). To align priorities for greater impact, the NEO QI Hub also engages community-based organizations, Medicaid Managed Care Plans, and other partners.
To incorporate the patient and consumer voice into the Achieving HEAlth Excellence in Diabetes (AHEAD) Initiative, the NEO QI Hub maintains a Patient Advisory Council of Medicaid-enrolled patients and family members with diabetes from participating clinics. Their recommendations are included at the end of this toolkit in a series called Patient Perspectives, and are designed to support health care teams to deliver more patient-centered care.