There are significant and persistent disparities in diabetes care and outcomes in among minoritized populations compared to white populations. There are also geographic disparities in diabetes control, especially between rural and urban populations and in those with greater and lower socioeconomic status.
Clinics participating in the NEO QI Hub will serve a large proportion of Medicaid patients and focus on eliminating disparities within their clinics. We will first assess baseline key health disparities within and across participating practices using EHR data. This baseline landscape of health disparities within the NEO QI Hub will guide the development of appropriate SMART (Specific, Measurable, Achievable, Realistic, and Time-framed) Aims focused on eliminating these disparities.
This toolkit has the following evidence-based resources and strategies to support the development of programs and interventions to eliminate disparities in diabetes health outcomes:
| Key Drivers | Evidence-Based Resources and Strategies |
| Key Driver A | Treatment algorithms prioritizing medications which can improve diabetes morbidity and mortality |
| Key Driver A | Continuous glucose monitoring and remote home blood sugar monitoring to overcome access to care and data to facilitate appropriate treatment and follow up |
| Key Drivers A, B, C, D, F | Standardized protocols to reduce implicit bias |
| Key Drivers A, B, C, D, F | Consistently identifying and addressing medication and visit adherence (e.g., 90-day prescriptions, multiple follow-up modalities such as staff-led visits, Community Health Worker, and telehealth) |
| Key Driver B | Outreach to patients using tailored approaches and team-based care, focused on those with care gaps |
| Key Drivers B, F | Leveraging telehealth to address transportation barriers/access |
| Key Driver E | Communication skill-building to build trusting relationships between patients and primary care teams, including cultural humility, health literacy, and implicit bias |
| Key Driver F | Health equity frameworks that center equity measurement and activities |
| Key Driver F | Identifying and addressing Social Drivers of Health (SDoH), anti-racism, and inclusion |