Over the last three years, Fort HealthCare (FHC) has been working on the Improving Diabetes for Healthier Communities program. The program was made possible by a grant through the Health Resources Services Administration (HRSA) awarded to FHC through its Small Health Care Provider Quality Improvement Program. 

Improving Diabetes for Healthier Communities added Comprehensive Care Management (CCM) and a teleophthalmology service. Other programs and services include advancing the Diabetes Self-Management Education and Support (DSMES) program and ambulatory pharmacy services. 

The CCM program provides patients with additional care and assistance between clinic visits with their providers to help them manage their diseases and improve their health outcomes. During the grant period, over 240 patients were enrolled (157 of those living with diabetes). 

The teleophthalmology service began screening for diabetic retinopathy with one retinal imaging camera and has since expanded to three cameras in the FHC service area. A total of 407 eye screenings were completed, which resulted in a 38.3% finding rate for diabetic eye disease, cataracts, or other eye issues. 

The DSMES program was advanced to improve patient engagement rates. FHC also extended ambulatory pharmacy services to advance a team-based approach for diabetes care. 

Fort HealthCare was also able to improve behavioral health screenings and collection and analysis of Social Determinants of Health (SDOH), which help identify social needs that may impact a patient's ability to manage their health. Today all patients are screened for depression and suicide risk using the appropriate screening tool in primary care clinics. FHC will continue efforts and services made through the Improving Diabetes for Healthier Communities program after the grant period.