NYC Health + Hospitals’ Diabetes Patients Achieve Highest Rate of A1C Control
An A1C level is indicative of how a patient is managing their diabetes
In 2021, the health system expanded its diabetes management program to include 36 pharmacists to assist patients with their diabetes management; nearly 64,000 patients are enrolled in the program
Uncontrolled diabetes can cause blindness, kidney disease, and lower extremity amputations in adults
Nov 30, 2022
NYC Health + Hospitals today announced its highest ever rate of A1C control among the nearly 64,000 primary care patients with diabetes. More than two-thirds (68.0%) of patients with diabetes have an A1C level, or blood sugar level, below 8%, meaning their diabetes is at or near goal, and only 16.5% of patients have significantly uncontrolled diabetes with an A1C level over 9%, the system’s lowest ever rate. In addition, the system increased teleretinal screenings by 20% from 10,000 per year in 2021 to 12,000 in 2022. Annual teleretinal screenings are a critical tool in catching diabetic retinopathy, the leading cause of blindness in U.S. adults aged 20-74, before symptoms develop. Patients with diabetes also have the highest ever rate of blood pressure control at 80.5%, in part due to distribution of home blood pressure monitors and measuring and documenting home blood pressure. Most diabetes-related deaths are due to cardiovascular disease, and diabetes doubles the risk of heart attack or strokes. High blood pressure is an independent risk factor for these outcomes. Since it is common for patients with diabetes to have high blood pressure, it is even more critical to control blood pressure in patients with diabetes.
These results follow the health system’s expansion of diabetes services in 2021, which included 36 additional pharmacists to help patients manage their medications, additional teleretinal machines, and peer mentoring for patients with diabetes. In addition, NYC Health + Hospitals nurses and outreach staff contact over 1,000 patients each month with high blood pressure or diabetes to keep them engaged in primary care, with a focus on patients who are uncontrolled and do not have an upcoming visit scheduled.
“A diabetes diagnosis can be frightening, but NYC Health + Hospitals is here to help you every step of the way,” said NYC Health + Hospitals Vice President and Chief Population Health Officer Nichola Davis, MD. “We’ve made it easy to get tested for diabetes during a primary care appointment, and if you have diabetes, you’ll have a team of people on your side, from your provider and nurse, to patient support groups and a peer mentor who’s been there.”
“NYC Health + Hospitals remains committed to not only fighting COVID-19 and other outbreaks but, equally, treating chronic diseases such as diabetes,” said Andrew Wallach, MD, FACP, Ambulatory Care Chief Medical Officer at NYC Health + Hospitals. “Our diabetes care teams support patients and provide access to the latest treatments and care.”
“While patients with diabetes can lead very long and healthy lives, managing the disease every day can be overwhelming,” said Hannah Jackson, MD, MPH, Assistant Vice President & Chief of Staff, Office of Ambulatory Care and Population Health at NYC Health + Hospitals. “By embedding our clinical pharmacists and teleretinal screening machines within the primary care clinic, we are able to decrease the barriers to comprehensive care these patients. Both of these programs have grown significantly over the last few years and have led to really important improvements in outcomes.”
“As the medication experts in the clinic, the Collaborative Drug Therapy Management pharmacists are integral members of our primary care teams,” said Josh Rickard, Senior Director of Collaborative Drug Therapy Management and clinical pharmacist at NYC Health + Hospitals/Queens. “They ensure our patients with diabetes are on optimal medication regimen’s to best control their blood sugar and prevent future complications.”
“The Primary Care Diabetes Program supports patients who have fallen out of care,” said Yesehac Araya, Diabetes Program Coordinator, Bellevue Primary Care Diabetes Program. “This involves monthly outreach to patients overdue for A1C testing. Once contact is established the diabetes team assists patients along the path of care coordination, bringing them in for a focused diabetes recall visit, with the ultimate goal of re-establishing connections to their primary care doctors.”
NYC Health + Hospitals’ diabetes management programs include:
- Clinical Pharmacists in Primary Care – Clinical pharmacists are integrated members of primary care teams to help diabetes patients manage their medications.
- Teleretinal Screening in Primary Care – Primary care sites offer teleretinal screenings as part of a routine visit for patients with diabetes, instead of requiring a separate ophthalmology appointment.
- Peer Mentors a Phone Call Away – Peer mentors, people who manage their diabetes and are trained to help other patients, can help address each patient’s barriers related to the social determinants of health while inspiring healthy lifestyle behavioral changes.
- A Coach in Your Pocket Smartphone App – The app provides real-time, individualized coaching, reminders, and support, as well as educational tools that are personalized for each patient to monitor and manage their type 2 diabetes. The app offers medication tracking, blood glucose meters, labs, activity trackers, articles and videos, healthy recipes and access to the user’s care team.
- Text Messages and Support for Insulin Adjustment – The text-based program optimizes insulin dosing for patients who are on insulin.
- In-person Educational Support in Primary Care – This includes diabetes classes, one-on-one sessions, and patient support groups.
Nearly one million New Yorkers have diabetes, and about 19 percent are undiagnosed. Uncontrolled diabetes can cause blindness, kidney disease, and lower extremity amputations in adults. Obese New Yorkers are two times more likely as other adults to have diabetes. Adults living in high-poverty neighborhoods are also at least twice as likely to report having diabetes compared to adults living in low-poverty neighborhoods. The average medical expenditures for people with diagnosed diabetes are about $16,752 per year, with about $9,601 of this being attributed to diabetes management directly.
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About NYC Health + Hospitals
NYC Health + Hospitals is the largest municipal health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs. A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system’s trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan—all supported by 11 essential hospitals. Its diverse workforce of more than 43,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. For more information, visit www.nychealthandhospitals.org and stay connected on Facebook at https://www.facebook.com/NYCHealthandHospitals or Twitter at @NYCHealthSystem.