Diabetes Promising Practices with Bay Area Community Health Center by Integrating Information Systems and Technology

Site: Fremont, California
Health Center Program Grantee: Bay Area Community Health Center (BACHC), formerly known as Tri-City Health Center

Bay Area Community Health Center (BACHC) in Fremont, California established a panel to produce better processes and results that have enhanced diabetes care among their patient population. This is managed by the health center’s wellness department with case managers, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Medical Assistants (MAs) that help coach all diabetes patients at BACHC. With the use of the panel, BACHC has been able to follow up with their patients daily and set up time frames on when their case managers will follow up with patients depending on their A1C levels. The higher the A1C levels, the more frequent the follow ups are for patients and coaching is available for them through telephone. 

Additionally, case managers also see patients right after their initial doctor visits to provide one-on-one counseling and hold diabetes-related classes that include nutrition and exercise information. This strategy has been shown to be effective as patients have seen a change in their blood glucose levels when comparing baseline glucose measurements prior to attending diabetes classes to after completing the classes.  

Tools provided for their patients also included the use of care messaging, where messages are sent out to patients through text messages by their coaches. This campaign was a 25-week long project.

For more information on this promising practices, go to Using Information Systems and Technology to Enhance Diabetes Care