A whole child model of care for pediatric Medicaid patients with type 1 diabetes to address health disparities and close care gaps
Background: The incidence of type 1 diabetes (T1D) is increasing in the US, mainly among Hispanic and non-Hispanic Black youth, and health disparities continue to increase among these racial and ethnic groups. California Kids Care (CKC) is a RCHSD pilot program that provides care to Medicaid insured patients serving 130 children with T1D. The study aims to decrease the percentage of high-risk patients (HbA1c >8%) from baseline of 67% to 55% in 10 months.
Methods: A multidisciplinary team created a patient and family centered review tool and identified key change concepts. These were tested in series of Quality Improvement cycles. Interventions included: use of the family-centered review tool by the CKC and Diabetes teams, patient assigned to a nurse care navigator who provides diabetes education reinforcement, facilitates communication and access to medication and supplies, monthly review meetings, EMR form tracking recommendations, and child life specialist telehealth visits.
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