Diabetes Initiatives

Diabetes Initiatives

Our diabetes initiatives, including the Diabetes Collaborative and the Community Engagement Initiative, help patients with diabetes who are living in underserved areas. These programs are dedicated to positively impacting individuals through:

  • Access to enhanced clinical care
  • Screenings
  • Diabetes awareness campaigns
  • Health education

Diabetes Collaborative

In response to the overwhelming need for comprehensive care for patients with diabetes who are living in medically underserved and predominantly minority populations, the following organizations have embarked on a strategy to address this need:

Together, we have developed and implemented a patient-centered, cost-effective care program that helps patients better self-manage their diabetes. The goal of the program is to help patients become more informed about their disease and manage it according to the best standard of care. Our model of diabetes care has been expanded to include two federally-qualified health centers, and the program components include access to care, diabetes education, and quality improvement.


The Diabetes Collaborative draws upon each organization’s areas of expertise, including:

  • Northwestern Memorial Hospital: Contributes expertise in diabetes care and patient education and provides critical funding for staff to organize and manage activities carried out through the program
  • The Feinberg School of Medicine: Contributes the expertise of its nationally-recognized Program in Communication and Medicine, which addresses effective communication with patients
  • Near North and Erie: Bring collective experience in providing community-based care to their predominantly African-American and Hispanic patients


This collaborative has helped patients improve their health and better manage their diabetes. Specific program outcomes include:

  • Decreased blood sugar levels
  • Achievement of self-management goals
  • Increased staff to better manage patients
  • Establishment of a Chronic Care Team to help patients reach their goals
  • Evaluation of barriers to care and establishment of protocols/policies to address barriers
  • Recognition by Mutual of America Awards Foundation (2009)

We also provided equipment and services to make serving patients easier, including:

  • Electronic medical records system to track and manage patients more efficiently
  • Seven culturally sensitive, bilingual (Spanish and English), and health literacy–appropriate patient education videos
  • Two visual field machines that are essential in the diagnosis and treatment of glaucoma—a preventable disease that can lead to blindness if not treated

To date, more than 2,300 patients with type 2 diabetes have been tracked through Near North’s registry of patients with diabetes, and nearly 500 patients from Erie’s Humboldt Park location have accessed the program. There are plans to implement the program at Erie’s other health centers in the near future.


In 2012, the Diabetes Collaborative began expanding to include CommunityHealth. We are currently working to build infrastructure at CommunityHealth so that we can track patient progress and measure program outcomes.

Community Engagement Initiative: Diabetes in Humboldt Park

The Diabetes Collaborative resulted in positive clinical outcomes for patients with diabetes, and demonstrated a proven track record for impacting diabetes in the community through increased registry size and decreased HbA1c rates.

Therefore, in 2009, the Collaborative recognized the need to advance the work done through this partnership to reach a wider audience. Using the Diabetes Collaborative model as the foundation, the team began laying the groundwork to expand this work to the broader community.

Through a study by Sinai Urban Health Institute, Humboldt Park was identified to have one of the highest rates of diabetes in the nation at 14 percent. In response to this alarming rate, Humboldt Park was chosen as the initial community, and Northwestern Medicine began collaborating with key community stakeholders.

These partners embarked on the Diabetes Initiative—a program that would continue efforts to increase access to care and strengthen healthy behaviors to improve health outcomes for those living in this underserved community.

The goal of the Diabetes Initiative was to achieve measurable improvements in the health outcomes of Humboldt Park residents by advancing a comprehensive, community-based intervention centered around diabetes awareness, education, early detection and enhanced clinical care.

The Diabetes Initiative was launched after conducting focus groups with community residents, organizations, and key leaders. Their feedback demonstrated the importance and power of partnering with the community, and lead to an initiative that incorporated diabetes management as well as risk reduction through healthy lifestyle changes.

During the past fiscal year, we have expanded our partnerships and engaged community residents in programs that address healthy nutrition, physical activity, screenings and education.

The main areas of focus include:

  • Increased overall awareness of healthy lifestyle behaviors, such as physical activity, healthy eating habits, weight loss/management and diabetes prevention
  • Empowerment of Humboldt Park residents to participate in health programs and classes
  • Data collection for those that take action to track program progress and outcomes

Diabetes Initiative partners continue to work collaboratively to develop and execute sustainable wellness strategies to:

  • Reduce risk factors and prevent/delay chronic disease
  • Promote wellness and improve management of chronic conditions
  • Monitor, evaluate and make recommendations to strengthen established processes to ensure achievement of our shared community goals