Optimizing Diabetes Management in Primary Care

Erie County Medical Center (ECMC) in Buffalo, NY, serves as the largest safety net hospital in the region, caring for a high-risk population disproportionately affected by healthcare disparities tied to socioeconomic status and racial/ethnic backgrounds. These disparities contribute to poor outcomes in chronic conditions like diabetes. Erie County has higher diabetes-related hospitalization and mortality rates than the rest of New York State, underscoring the urgency of effective diabetes control.
The primary objective of this project (optimizing diabetes management in primary care) was to develop and implement a comprehensive diabetes management protocol to enhance patient outcomes and streamline care delivery. This initiative sought to address transportation challenges, improve patient awareness, and promote adherence and self-management behaviors. By tailoring interventions—including lifestyle modifications, medication counseling, education, outreach, and care coordination—to each patient’s unique needs, the project actively addressed social determinants of health (SDOH), such as health literacy and transportation barriers, within a team-based care model.
Between 2021 and 2024, ECMC’s targeted intervention program, developed and led by an RN, significantly improved diabetes management outcomes. The proportion of patients achieving glycemic control rose from 49.9% to 66.8%, reflecting a 33.87% improvement. The average A1C among primary care patients decreased to 7.3. Evidence-based strategies, including personalized education, regular monitoring, and team-based care delivery drove these improvements.
This project demonstrates the transformative potential of addressing SDOH and disparities through structured evidence-based protocols. It highlights the critical role of innovative nursing practices in improving diabetes outcomes and advancing health equity in underserved populations.
Learning outcome: By the end of this poster session, attendees will be able to identify evidence-based strategies for improving diabetes management in underserved populations, recognize the impact of addressing social determinants of health on patient outcomes, and apply a team-based care model to enhance adherence and self-management behaviors in their own practice.