Behavioral Health Integrator

As of CDC's 2017 National Diabetes Statistics Report, 30.3 million people, or 9.4% of the total U.S. population, have diabetes. Of these 30.3 million, only 23.1 million are diagnosed—while the other estimated 7.2 million are undiagnosed. Additionally, more than 1 in 3 adults or 84.1 million people in the U.S. have prediabetes, including nearly half of people age 65 and older. According to 2018 UDS data, an estimated 15.1% of Federally Qualified Health Center patients nationwide have diabetes, an increase over recent years. Of these approx. 2.4 million plus patients living with diabetes, approximately 33% have uncontrolled diabetes, with HbA1c equal to or above 9% or have had no test in the year. This has remained relatively stable since 2016. These statistics bring forth the need for improvement in the care of diabetes; several resources and research outcomes are profiled here with specific takeaways for health centers.

This document includes tips for selecting and implementing population health management analytic and integrated data systems derived from Primary Care Associations, Health Center Controlled Networks, and health centers who have gone through this experience.

It is sometimes difficult to know what target metric to focus on when beginning a quality improvement project. A prioritization matrix is a management tool that uses a simple framework to compare multiple options side-by-side using standard criteria. This version includes four criteria and can be adapted for your purposes.

 A Project Charter serves as a reference of authority for the future of the project. Creating a Project Charter and getting sign off from all participants gives all involved the authority to begin the work outlined therein. The task of developing the Project Charter builds understanding, consensus, and clarity about purpose, expectations, roles and responsibilities, and communications.

Examples of Technical Assistance Provided by Primary Care Associations and Health Center Controlled Networks