Plan for diabetes California's - our work in diabetes

A coordinated
plan to help guide
     our work in diabetess


     plan for diabetess

Developed by the Diabetes in California Task Force
Table of Contents
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
  ■   The impact of diabetes in California
  ■   Contributing factors to a growing trend
  ■   Gaps in diabetes care

California’s Plan for Diabetes: 2003-2007. . . . . . . . . . . . . . . . . . . . . . . . . 6
  ■   Plan roadmap
  ■   Data collection and measurement
  ■   Using the Plan

Plan Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
  ■   Goal 1: Increase access to care
  ■   Goal 2: Improve quality of care
  ■   Goal 3: Promote primary prevention
  ■   Goal 4: Guide public policy

Call to Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
— John F. Kennedy
Summary                                             recommended interventions,
                                                                and expected outcomes when the
                                                                interventions are implemented.
                       Diabetes, a serious disease and major
                                                                Importantly, we also suggested
                       public health problem, is sweeping
                                                                measurement or evaluation tools
                       the country. California has approxi-
                                                                that could be used to monitor
                       mately two million people with
                                                                progress and determine when we
                       diabetes and a growing number
                                                                have achieved our goals. When
                       with pre-diabetes. Many excellent
                                                                a draft of the Plan was complete,
                       programs and initiatives exist in
                                                                we posted it on the Internet and
                       California to address diabetes, but
                                                                took it on the road to gather input
                       with major budget challenges and
                                                                at ten community meetings held
                       an exploding epidemic, it is essential
                                                                in cities throughout California.
                       that we work together to coordinate
                                                                We wanted this five-year plan to be
                       efforts and leverage our impact on
                                                                realistic and achievable, and serve as
                       this devastating disease.
                                                                a useable guide for work in diabetes.
                       California’s Plan for Diabetes           Therefore, we did not address every
                       (the Plan) was developed to help         problem or concern in diabetes.
                       organizations in their work to combat
                                                                The Plan serves three primary pur-
                       diabetes. The Plan belongs to the
                                                                poses. First, it assists state and local
                       people of California, as we are all
                                                                organizations in meeting national
                                                                objectives for diabetes, as defined
    “Diabetes is like a tsunami wave that                       by such initiatives as Healthy People
       has been developing force and                            2010 and the National Diabetes
                                                                Objectives established by the Centers
      is crashing down on California.”                          for Disease Control and Prevention.
                                                                Second, the Plan is meant to guide
                       impacted by diabetes. Many
                                                                organizations in their chosen
                       people throughout the state con-
                                                                activities insofar as they address
                       tributed to the development of the
                                                                diabetes as a major health concern in
                       Plan. Initially, a multi-disciplinary
                                                                California. Finally, the Plan promotes
                       group came together to identify
                                                                collaboration between organizations
                       broad topics or goals needed to be
                                                                in order to strengthen their combined
                       achieved in diabetes. Within each
                                                                efforts in addressing diabetes.
                       goal we identified priority areas,

Introduction                                  compromise people’s quality of
                                              life, affect their ability to contribute
                                              to their communities and cost great
     The impact of diabetes                   amounts to manage and treat.
     in California                            Spending in the United States for
     Diabetes Mellitus (diabetes) is a        diabetes was over $100 billion in
     prevalent and serious public health      1992, or $10,071 per person with
     concern, which has grown so rapidly      diabetes, compared to $2,699 per
     in recent years that representatives     person without diabetes6. California’s
     of the federal government call the       share of this cost was approximately
     disease “a national epidemic1.” The      $12 billion from all sources. Although
     disease affects more than 17 million     California’s estimate is enormous,
     people nationwide, and approxi-          it is probably a conservative one
     mately two million people have           because lost wages, productivity,
     diabetes in the state of California2.    nursing home care costs, and nonpre-
     In the 1990s, the prevalence of type 2   scription drugs are not included. Each
     diabetes in California increased by      year there are over 300,000 diabetes-
     33 percent overall, and 70 percent       related hospitalizations in California,
     among people in their 30s3. The total    at an annual cost of $3.4 billion7.
     number of people with diabetes in
     California is expected to double by      Contributing factors

     the year 20204.                          to a growing trend
                                              The two major forms of diabetes are
     In addition to being the sixth leading   called type 1 and type 2, and both
     cause of death in the United States5,    cause similar kinds of complications.
     diabetes contributes to the serious      Gestational Diabetes Mellitus (GDM)
     effects of other conditions. Diabetes    is also an important form of diabetes
     is the leading cause of major medical    with onset or first recognition during
     problems, including adult blindness,     pregnancy. GDM complicates
     kidney failure, non-traumatic ampu-      approximately 7 percent of all preg-
     tation of the lower limbs, and is        nancies in the United States and is
     a significant contributor to heart       a risk factor for later development
     disease and stroke. Furthermore,         of type 2 diabetes8. Type 1 diabetes
     serious birth defects may occur in       is caused by a failure of the pancreas
     the offspring of mothers with dia-       to make insulin due to autoimmune
     betes. All of these complications        destruction of the insulin producing

beta cells and accounts for about 5-         of diabetes that has until recently
                          10 percent of all cases . Those with         been diagnosed primarily in adults.
                          type 1 diabetes must take insulin to         Some recent reports indicate that
                          stay alive and perform multiple daily        8–45 percent of children with newly
                          blood glucose (sugar) tests to assist        diagnosed diabetes have type 2 dia-
                          with treatment decisions. Type 2             betes12. These children are typically
                          diabetes, due to insulin resistance          overweight, 10 years of age or older,
                          and relative insulin deficiency,             a member of a high-risk ethnic
                          accounts for 90-95 percent of all            group, and have a family history
                          cases. Risk increases with age, obesity      of type 2 diabetes.
                          and a sedentary lifestyle. Weight
                                                                       Diabetes affects some populations
                          reduction and physical activity have
                                                                       disproportionately, including African
                          been shown to reduce the risk of
                                                                       Americans, American Indians/
                          developing type 2 diabetes and to
                                                                       Alaskan Natives, Asian and Pacific
                          slow its progression. But obesity, one
                                                                       Islanders, Hispanics/Latinos, and the
                          of the leading health indicators for
                                                                       elderly. With an aging population
                                                                       and over half of the state composed
      “Everyday we see the devastation that                            of high-risk ethnic populations,
    diabetes causes. But others may not see it.                        it is not surprising that diabetes
                                                                       is increasing rapidly in California.
    Diabetes is not contagious nor is it always
                                                                       Another trend is the growing
     visible. It’s hard to convince people that                        population of people with Impaired
                 it’s serious, but it is.”                             Glucose Tolerance or Impaired
                                                                       Fasting Glucose, now called “pre-
                          the Healthy People 2010 initiative, is       diabetes,”who have higher than
                          a significant problem in our country,        normal blood glucose (sugar) levels
                          with over half of the adult population       and are expected to be diagnosed
                          considered overweight or obese . In10
                                                                       with type 2 diabetes within a decade.
                          2000, 15 percent of children under           After finding that 16 million
                          age 19 were considered obese,                Americans between 40 and 74 years
                          compared to 4-6 percent in 1974 .       11
                                                                       old have this newly defined type 2
                                                                       diabetes precursor, federal health
                          As a result of this increase in obesity,
                                                                       officials and the American Diabetes
                          more children and adolescents are
                                                                       Association recently issued guidelines
                          developing type 2 diabetes—a form

recommending increased screening         is known to be
for pre-diabetes . Pre-diabetes can      effective in dia-
lead to type 2 diabetes and increase     betes care, and
the risk of developing heart disease     the care that is
by 50 percent. However, lifestyle        actually provided.
changes such as moderate physical
                                         The reasons for
activity and a more nutritious diet,
                                         this gap are
can lead to moderate weight loss and
                                         multiple and
may delay or prevent the onset of
                                         complex. They
type 2 diabetes, if the condition is
                                         include: a frag-
detected early.
                                         mented and
Gaps in diabetes care                    confusing health
Effective screening and treatment        care delivery sys-
methods exist for diabetes, yet many     tem; increasing
people do not receive appropriate        numbers of unin-
care. In an effort to improve the        sured and under-
quality of medical care and heighten     insured Californians; limited public     encourage populations to improve
the level of awareness regarding         resources for diabetes treatment and     their lifestyle choices. Our societal
basic health care requirements for       prevention; overburdened primary         influences do not support healthy
those with diabetes, the Diabetes        care physicians who are expected to      lifestyle changes. Many people work
Coalition of California, in collabora-   deliver the majority of clinical man-    long hours in sedentary jobs, live
tion with the California Diabetes        agement; and lack of incentives to       in areas that have limited physical
Prevention and Control Program,          coordinate and improve systems of        activity options, are surrounded by
issued Basic Guidelines for Diabetes     care. Complicating the issue further     unhealthy food choices, such as an
Care ( These        is an increasingly obese and seden-      overabundance of junk food and fast
evidence-based guidelines, which         tary population, creating more stress    food restaurants, and face a growing
serve as a framework for the             on a system already failing to deliver   acceptance of increased portion sizes.
development of diabetes care pro-        effective care in many instances.        Overcoming these environmental bar-
grams and strategies, are aimed at                                                riers requires consistent commitment
                                         In addition to challenges within
reducing the personal and societal                                                and diligence, as well as valuable time
                                         the health care system, providers
impact of diabetes. There is still                                                and resources.
                                         are now struggling to assist and
a gap nonetheless, between what

California’s Plan for                                                      risk for, dia-
                                                                                    betes. The Plan
                                                                                    does not outline
         Diabetes: 2003-2007                                                        every possible
                                                                                    solution, but
                     Because diabetes is a large and          primarily focuses on those interven-
                     complicated health problem, there        tions that are practical, achievable,
                     is a need for a comprehensive action     and realistic in the current California
                     plan that promotes and advocates         health care environment.
                     for coordinated diabetes care in
                                                              While all populations are considered
                     California. Many organizations in
                                                              for interventions, this Plan gives
                     California are already doing excellent
                                                              special attention to high-risk ethnic
                     work in diabetes, yet these efforts
                                                              groups, overweight children and
                     frequently occur in isolation, with
                                                              adolescents, older adults and the
                     little interaction between other
                                                              economically disadvantaged. The
                     organizations that are doing similar
                                                              Plan is grounded in current evidence
                     or complementary work. California’s
                                                              when proposing specific interven-
                     Plan for Diabetes provides a frame-
                                                              tions, and proposes measurable
                     work for these organizations to
                                                              objectives and outcomes that can
                     mobilize around a single set of
                                                              be expected upon implementation.
                     common goals: to increase access
                                                              This report is written for many
    “It is our duty to provide hope,                          types of entities, ranging from local
                                                              community based organizations
          even though at times,                               (CBOs) to governmental agencies.
       diabetes seems hopeless.”                              The important aim of this Plan is
                                                              the coordination of diabetes work
                     to care, improve the quality of care,    among organizations, providing
                     enhance primary prevention and           focus and promoting collaboration.
                     guide public policy for diabetes.
                                                              The goals were established by a task
                     Plan roadmap                             force composed of key agencies and
                     Just as diabetes affects multiple pop-   organizations across the state that
                     ulations in myriad ways, there are       have identified diabetes as a clinical
                     many interventions that can achieve      or community priority. Community
                     improved health in those with, or at     input was gathered through a series

of meetings statewide, where local        a sophisticated data collection           of programs for high-risk populations,
organizations provided feedback on        system, but this should not preclude      and implementation of health
the Plan. In addition, the Plan was       them from participating in outcomes       improvement programs for persons
available on the Internet for public      measurement. An infrastructure for        with diabetes. To assist organizations,
comment. The goals defined through        collecting, analyzing, and distributing   the California Diabetes Prevention
these meetings were:                      accurate data to relevant stakeholders    and Control Program is offering its
                                          is absolutely essential in order to       reporting tool (available at
■   Access: Identify and reach a larger
    number of Californians with, or at    assess progress and make informed to facilitate the process.
    risk for, diabetes                    programmatic decisions.                   This tool can be used to report data
                                                                                    on all six key measures. Patient
■   Quality Care: Promote guidelines      The California Diabetes Prevention
                                                                                    identifiers will not be collected and
    and strategies to improve care        and Control Program has created
    delivery                                                                        if desired, the submitting organiza-
                                          a reporting tool to help meet
                                                                                    tion’s identity will not be disclosed.
■   Primary Prevention: Increase          requirements in providing data
                                                                                    Data can of course be collected in
    awareness, knowledge and action       to the Centers for Disease Control
                                                                                    any clinical or program area, but the
    regarding diabetes prevention         and Prevention. The California
                                                                                    tool focuses on the six key measures.
■   Policy: Guide public policy related   Diabetes Prevention and Control
                                                                                    We encourage you to report your
    to diabetes                           Program gathers information across
                                                                                    data to the California Diabetes
                                          six key measures (National Diabetes
Each goal is outlined below, including                                              Prevention and Control Program
                                          Objectives): foot exams, eye exams,
priority areas, proposed interventions,                                             so it can be used in measuring
                                          influenza and pneumococcal vac-
and the change that is expected upon                                                California’s progress in meeting the
                                          cines, A1C tests, reduction of health
implementation of interventions.                                                    National Diabetes Objectives.
                                          disparities through implementation
A coordinated and integrated
approach to improving diabetes
care in California through the year
2007 is possible, and this Plan serves
as a guide for all to accomplish that

Data collection
and measurement
For most organizations, collecting
and analyzing data for diabetes
activities is an ongoing challenge.
It is understood that many organiza-
tions in the state do not have
4. Select recommended interven-
                                                                                            tions from the Plan that support
                                                                                            priority areas. Select those that are
                                                                                            realistic and achievable for your
                                                                                            organization. Consider collabora-
                                                                                            tions with other organizations to
                                                                                            utilize outside resources and

                                                                                         5. Identify leadership and
                                                                                            intended beneficiaries in your
                                                                                            community. Create and imple-
                                                                                            ment interventions that consider
                                                                                            the needs of your community,
                                                                                            well as utilize local leadership
    Using the Plan                            1. Review your organization’s
                                                                                            to further goals.
    In order to accommodate the varying          mission statement. Define or
    resources and needs of organizations,        reconfirm which areas are of the        6. Create infrastructure for
                                                 highest priority to your own               measurement and data
    the Plan offers a host of areas for
                                                 organization.                              collection. Using an internal
    potential focus, as well as numerous
                                                                                            data collection system, and/or
    proposed interventions to begin or        2. Identify those goals from the
                                                                                            the tool provided by California
    continue work in those areas. It is          Plan that are most in alignment
                                                                                            Diabetes Prevention and Control
                                                 with your organization’s mission.
    understood that many entities are                                                       Program, collect appropriate
                                                 Within the relevant goals, select
    already focusing their efforts in the                                                   data, collate it, and share the
                                                 priority areas for your organization,
    defined priority areas, and instead                                                     data with the California Diabetes
                                                 assigning timeframes to specific
    of taking on new program develop-                                                       Prevention and Control Program
                                                 activities for the years 2003-2007.
                                                                                            and other partners.
    ment, will opt for more guidance
                                              3. Contact other community
    in aligning their work with other                                                    7. Revisit progress on priority
                                                 organizations in order to review
    California organizations.                                                               areas periodically and monitor
                                                 and discuss their own priority
                                                                                            outcomes, both internally, and
                                                 areas. Create a community-wide
    This Plan was crafted with the under-                                                   with other organizations in the
                                                 plan to ensure that key priority
    standing that most organizations                                                        community. Stay connected to
                                                 areas are covered and duplication
    have limited time and resources. It                                                     community resources to ensure
                                                 of effort is reduced. Then institute
    is recommended that you follow the                                                      delivering needed services.
                                                 a communication mechanism
    next seven steps to maximize your            for updating all organizations
    organization’s efforts in incorporating      on progress.
    the Plan.

diabetes and work towards the
                                           elimination of disparities in health
                                           care. More Californians with, or at
                                           risk for, diabetes will be identified,
                                           and gain access to appropriate
                                           screening, treatment and education.
                                           As a result, fewer complications
Critical tasks                             will result from inconsistent self-
For myriad reasons, many people            management, and undiagnosed
with, and at risk for, diabetes do         and under-treated diabetes.
not receive appropriate care. This
                                           To measure these important changes
is particularly true in high-risk ethnic
                                           use data sources such as: Behavioral
populations, children and adoles-
                                           Risk Factor Surveillance Survey
cents, pregnant women, older adults
                                           (BRFSS); California Health Interview
and the economically disadvantaged.
                                           Survey (CHIS); California Cooperative
The table below summarizes the
                                           Health Care Reporting Initiative
priority areas and recommended
                                           (CCHRI); Bureau of Primary Health
interventions to identify and reach
                                           Care (BPHC) Health Disparities
a larger number of Californians with,
                                           Collaborative; U.S./Mexico Border
and at risk for, diabetes.
                                           Diabetes Project; Medicare/MediCal;
Evidence of Change                         and local county data.
Successful implementation of this
goal will lead to increased access to
care for people with, or at risk for,

     “We know that people with diabetes
   do best with continuous care, but if they
      only have seasonal health coverage,
       the continuity of care is broken.”

PRIORITY AREAS                RECOMMENDED INTERVENTIONS                                    EXPECTED OUTCOMES

     1.A Identify specific   ■   Use existing local and California data (i.e.       ■   Increased use of local and state data to identify
     populations within          California Diabetes Prevention and Control             underserved populations.
     your own community          Program County Fact Sheets) to find                ■   Increased number of organizations collecting
     or organization with        underserved populations with, and at risk              data.
     increased diabetes          for, diabetes.
     prevalence or high-     ■   Begin process for collecting data for diabetes
     risk, and either poor       if no local data exists.
     or no access to care.

     1.B Promote better      ■   Perform community assessment (e.g.                 ■   Community assessments are conducted,
     alignment of       to determine                 existing services, needs and gaps are identified.
     services to needs,          existing services and gaps in diabetes             ■   Increased number of new and maintained
     at both local and           prevention and treatment to clearly define             collaborative partnerships established with
     state levels.               population needs. Gaps may include                     community, state and national programs aimed
                                 discontinuity of care, lack of culturally              at reducing health disparities for high-risk
                                 appropriate services, transportation/mobility          diabetes populations.
                                 barriers, and lack of services for high-risk
                                 populations.                                       ■   Increased use of self-management tools such
                                                                                        as the Diabetes Health Record card.
                             ■   Create plan for addressing gaps using collabora-
                                 tive approach and working with partners to         ■   Chart transfer mechanisms for providers
                                 prioritize and fulfill remaining needs.                are created.
                             ■   Encourage use of self-management tools,            ■   Tracking registries are developed.
                                 i.e., Diabetes Health Record card                  ■   Increased availability of culturally appropriate
                                 ( for patients to track            services.
                                 their own medical care.                            ■   Programs throughout California plan and
                             ■   Create mechanisms for doctors to transfer              implement more targeted and effective
                                 charts when patients change care provider.             programs, based on the needs and populations
                             ■   Create registry that tracks care when patients         identified.
                                 change plan or site of care.
                             ■   Create services that are culturally appropriate.

     1.C Promote broad       ■   Educate clinicians and health care personnel       ■   Increased number of clinicians and health care
     reaching access to          about diabetes risk factors, prevention,               personnel educated.
     diabetes services           diagnosis and treatment.                           ■   Increased number of community health
     and tests through       ■   Promote community health workers                       workers recruited, hired and trained.
     CBOs, health care           participation in diabetes prevention and
     facilities, social                                                             ■   Increased number of people can effectively
                                 treatment programs.                                    navigate through health care systems.
     services and
     community health        ■   Publicize when, where and how to access
     workers.                    diabetes services.

                                                Table 1. Increasing Access to Care

Goal 2: Improve                               Evidence of Change
                                              Successful implementation of these
                                              interventions will result in increased
quality of care                               system, provider and patient support
                                              for early diagnosis and coordinated
     Critical tasks                           care delivery strategies for diabetes
     Although evidence demonstrates that      care that match the cultural needs
     there are effective means of deliver-    of the population. There will be
     ing appropriate diabetes interven-       greater adoption of team-based
     tions, many providers and patients       approaches in clinical offices that
     are unaware of them. These missed        use care guidelines, including the
     opportunities can be due to frag-        use of self-management training,
     mented health care systems, inade-       and better integration of community
     quate provider and patient training,     resources as part of a total system
     or simply to the choices of providers    of care. Widespread use of coordinat-
     and patients not to adhere to the        ed care models will result in more
     most effective treatment plans. The      patients receiving effective care.
     table below outlines the priority
                                              To measure these important changes
     areas in implementing guidelines and
                                              use data sources such as: BRFSS;
     strategies to improve care delivery,
                                              CHIS; CCHRI; BPHC Health
     with recommended interventions for
                                              Disparities Collaborative;
     each area. The table is separated into
                                              U.S./Mexico Border Diabetes
     three categories of interventions:
                                              Project; Medicare/MediCal;
     system, provider and patient.
                                              and local county data.

           “Developing treatment guidelines
         was key. We’ve done that. Now we’ve
          got to use them in health systems
                  to create change.”

PRIORITY AREAS                 RECOMMENDED INTERVENTIONS                                      EXPECTED OUTCOMES

     System                   ■   Conduct projects to evaluate effectiveness of        ■   Evaluation projects conducted for coordinated
     interventions:               coordinated delivery models of care.                     delivery models of care.
     2.A Evaluate, critique   ■   Create common measures across state to allow         ■   Increased number of programs using
     and disseminate              cross-sectional and longitudinal evaluations of          coordinated delivery models of care.
     coordinated                  coordinated delivery models of care.                 ■   Increased number of providers aware of
     delivery models for      ■   Develop and support community                            coordinated care delivery models through
     common California            collaboratives to train and encourage providers          web sites, community meetings and
     systems of care, such        to use coordinated delivery models of care.              presentations attended.
     as Individual Practice
     Associations (IPAs),     ■   Research, catalog and share information about        ■   Increased number of trainings conducted for
     Preferred Provider           existing models of coordinated care via web              health care professionals on coordinated care
     Organizations (PPOs),        sites, community meetings and presentations.             delivery models.
     large medical groups,        (i.e. www.qualityhealth and                 ■   Increased number of academic institutions
     and community                                    incorporating training on coordinated care
     clinics.                 ■   Conduct training and ongoing education on                delivery models in curricula.
                                  effective coordinated care delivery models for       ■   Mechanism developed for care coordination
                                  health care professionals.                               among providers.
                              ■   Work with academic institutions to integrate         ■   Increased number of people with diabetes
                                  effective coordinated care delivery models as            receiving recommended A1C tests, eye
                                  a component of their training curricula.                 exams, foot exams, influenza and
                              ■   Develop a mechanism to coordinate care                   pneumococcal vaccines.
                                  among providers when patients change
                                  medical providers.

     Provider                 ■   Promote the importance of diabetes risk              ■   Increased number of people whose risk factors
     interventions:               assessment and screening/diagnostic testing              are assessed.
     2.B Promote and              in high-risk groups such as ethnic populations,      ■   Increased number of people are referred for
     support earlier and          the elderly, pregnant women, school age                  diagnostic testing.
     more frequent                children and those who are overweight
                                  or obese.                                            ■   Increased frequency of diagnostic testing for
     diabetes risk                                                                         people at high-risk and 45 years or older.
     assessment and           ■   Promote the use of the American Diabetes
     diagnostic testing.          Association’s Risk Test (a paper risk
                                  assessment tool) to identify high-risk
                                  individuals ( Persons
                                  identified to be at high-risk should be referred
                                  for diagnostic testing.
                              ■   Use alternate venues such as health fairs,
                                  schools and work sites to identify persons
                                  at risk for diabetes (Note: organizations using
                                  finger stick testing as a screening method
                                  must do so with a Clinical Laboratory
                                  Improvement Amendments (CLIA) license,
                         Those identified to be
                                  at risk should be referred for diagnostic testing.
                              ■   Conduct and track diabetes screening/
                                  diagnostic testing within health care delivery
                                  systems for those 45 years or older. For those
                                  at high-risk, screening should be done more
                                  frequently or at an earlier age.
                                                                                                                    (continued on next page)

                                                 Table 2. Improving Quality of Care


2.C Identify and         ■   Recruit and train culturally competent health     ■   Increased number of culturally competent
implement model              care professionals.                                   health care professionals.
strategies to            ■   Promote the use of clinical practice guidelines   ■   Increased number of providers trained and
address gaps in              and education materials by providers in high-         using clinical practice guidelines.
quality of care.             need areas. Combine with guideline training
Gaps may include                                                               ■   Increased number of providers trained and
                             for providers as necessary, to increase               using coordinated care delivery models.
lack of cultural             knowledge of the essential diabetes tests
competency, clinical         and exams.                                        ■   Increased number of providers receiving
knowledge, or                                                                      compensation for meeting diabetes
continuity of care.      ■   Conduct trainings with providers on                   performance measures.
                             coordination of care strategies throughout
                             health care systems.                              ■   Increased number of persons with diabetes
                                                                                   receiving recommended A1C tests, eye exams,
                         ■   Link to Integrated Health Care Association’s          foot exams, influenza and pneumococcal
                             (IHA) Pay-for-Performance Initiative to               vaccines.
                             promote diabetes tests/exams (

2.D Promote a team-      ■   Work with health plans, provider groups and       ■   Increased number of health care delivery
based approach to            other health delivery systems to deliver              systems using a team-based approach to
diabetes care delivery       messages and tools to enhance team-based              diabetes care.
that includes:               care and to promote appropriate testing and       ■   Increased number of nurse educators and
■   People with              treatment.                                            community health workers linking individuals
    diabetes and their   ■   Utilize nurse educators based at schools or           to health care systems and engaged with the
    families                 school districts and community health workers         health care team.
■   Health care              to link individuals to health care systems.       ■   Increased number of people with diabetes
    administrators       ■   Work with community groups, community                 receiving recommended A1C tests, eye exams,
■   Health care              health workers, school personnel, people with         foot exams, influenza and pneumococcal
    providers                diabetes and their families to understand the         vaccines.
                             team concept and their role on the team.
■   Public health
■   Community health
■   School personnel

Patient                  ■   Encourage patients to use self-management         ■   Increased use of self-management tools such
interventions:               tools, i.e. Diabetes Health Record card               as the Diabetes Health Record card.
2.E Empower                  (, to improve                 ■   Increased use of culturally and linguistically
people with                  communication with health care providers              appropriate educational materials.
diabetes to                  during clinical encounters.
                                                                               ■   Increased number of patient trainings
participate actively     ■   Distribute culturally specific educational            on self-management.
in their care and            materials at appropriate literacy levels about
communicate                  diabetes self-management.                         ■   Increased number of consumer groups
effectively with their                                                             promoting principles of active self-
                         ■   Organize consumer groups consisting of                management.
health care team.            people with diabetes who will promote
                             principles of active self-care to others with     ■   Increased number of non-medical sites
                             diabetes, i.e. Diabetes Consumer Action               promoting self-management.
                             Groups (                     ■   Increased number of people with diabetes
                         ■   Utilize non-traditional sites such as schools,        receiving recommended A1C tests, eye
                             work sites and faith-based organizations to           exams, foot exams, influenza and
                             promote active self-management.                       pneumococcal vaccines.

Goal 3:                                        and risk factors, in particular the link
                                                    between obesity and type 2 diabetes.
                                                    Awareness will also increase around
     Promote primary                                the steps needed to prevent type 2
                                                    diabetes, particularly among children

     prevention                                     and adolescents, their parents and
                                                    overweight individuals. Greater
          Critical tasks                            awareness among providers will lead
          With diabetes rates rapidly increasing,   to clear and consistent prevention
          a surge in obesity, and the recent        messages in the clinical setting and
          acknowledgement of pre-diabetes as        the community. Greater participation
          a health priority, there is a need for    among community organizations
          targeted primary prevention efforts.      will encourage local policies that
          The table below summarizes priority       recognize risk factors for type 2 dia-
          areas in increasing knowledge,            betes, support healthy food choices
          awareness and action around type 2        and provide physical activity pro-
          diabetes prevention, with recom-          grams in schools and communities.
          mended interventions for each area.
                                                    To measure these important changes
          Evidence of Change                        use data sources such as BRFSS and
          Successful implementation of these        CHIS. In addition, track media mes-
          interventions will result in messages     sages and campaigns, peer educators’
          being broadly disseminated that           activities, primary prevention meth-
          describe how to prevent type 2            ods, and policy changes to improve
          diabetes. There will be increased         healthy food consumption and
          awareness of diabetes prevention          physical activity programs.

                 “There needs to be a paradigm shift
                 where healthy habits are rewarded
                   in our health systems instead of
                 reimbursements that only pay once
                           someone is sick.”

PRIORITY AREAS                 RECOMMENDED INTERVENTIONS                                   EXPECTED OUTCOMES

3.A Design/identify      ■   Form partnerships to establish new or utilize     ■   Increased number of partnerships formed
and implement                existing programs that promote wellness,              to address chronic disease/type 2 diabetes
diabetes prevention          physical activity, weight control and healthy         prevention.
activities that focus        eating for people at risk for chronic diseases    ■   Increased media coverage about type 2
on the link between          including type 2 diabetes. Encourage use of           diabetes prevention and its link with obesity.
obesity and                  these programs at work sites, schools,
diabetes, particularly       community centers, etc.                           ■   Talking points developed and distributed on
targeting children and                                                             lifestyle modification, weight management,
                         ■   Utilize general and ethnic media as well as           healthy eating and physical activity.
overweight, high-risk        community resources to present messages to
adults.                      the public about diabetes risk factors and
                         ■   Develop talking points for teachers, clergy
                             and parents to address issues of lifestyle
                             modification, weight management, healthy
                             eating and physical activity.

3.B Educate              ■   Work with partner organizations involved          ■   Increased number of projects implemented for
providers to adopt           in nutrition and physical activity to promote         persons at risk for diabetes that are aimed at
primary prevention           simple, consistent messages that providers            lifestyle modification, promotion of wellness,
practices with high-         can use with high-risk patients and families.         physical activity, healthy nutrition and weight
risk individuals.            Incorporate behavior change methodology               management.
                             into messages.                                    ■   Increased number of provider champions and
                         ■   Find community provider champions to serve            easy-to-use tools.
                             as messengers; support through provision of       ■   Increased number of diabetes prevention
                             easy-to-use tools (i.e. talking points for            collaboratives.
                             provider-patient discussions about overweight,
                             sedentary lifestyle, and nutrition).
                         ■   Develop and support diabetes prevention
                             collaboratives between communities and
                             health care delivery systems.

3.C Change               ■   Participate in policy changes and efforts to      ■   Increased number of successful policies made
community                    improve healthy food consumption and                  to support healthy food choices and physical
environment to               physical activity programs in schools and             activity programs in schools and communities.
support and promote          communities.                                      ■   Increased number of local partnerships created
primary prevention       ■   Form partnerships with local agencies to assess       encouraging community change to support
of type 2 diabetes.          community environment and prioritize                  healthy lifestyles.
                             changes needed to support healthy lifestyles.     ■   Increased number of choices for physical
                                                                                   activity and healthy food in neighborhoods,
                                                                                   schools and work sites.

                                                Table 3. Primary Prevention

Goal 4: Guide                                 Evidence of Change
                                                   Successful implementation of these
                                                   interventions will result in sustained
     public policy                                 changes that support appropriate dia-
                                                   betes prevention and treatment and
          Critical tasks                           discoveries that will lead to a cure.
          Effective diabetes prevention and
                                                   To measure these important changes
          treatment requires a shift in policies
                                                   use data sources such as BRFSS and
          that support population based
                                                   CHIS. In addition, track enactment
          improvements. Scientific advances
                                                   of legislation or policies that expand
          that result in improved treatment
                                                   access to self-management training,
          methods and cures require policies
                                                   funding, and research.
          that further these discoveries. The
          table below identifies the priority
          areas in influencing public policy
          around diabetes, with recommended
          interventions for each area.

PRIORITY AREAS                RECOMMENDED INTERVENTIONS                                     EXPECTED OUTCOMES

4.A Enhance             ■   Collaborate locally to identify high-priority       ■   Increased number of communities that
legislative and             community issues and advocate for targeted              have action plans to address legislation and
regulatory advocacy         solutions.                                              policy issues.
at state and at local   ■   Target specific legislators and identify specific   ■   Increased contact with policy makers
levels.                     action steps for policy interventions.                  and legislators.
                        ■   Elicit testimonials, patient stories, and case      ■   Increased number of people equipped
                            studies from organizations, and share with              to testify.
                            policy-making bodies/committees.                    ■   Appropriate legislation and policies passed
                        ■   Develop talking points for people affected              and implemented.
                            by diabetes and support advocacy training           ■   Increased number of legislators who receive
                            in the community.                                       and acknowledge the Plan.
                        ■   Request town hall meetings with elected
                            officials for implementing priority areas.
                        ■   Use the Plan as a communication tool with
                            legislators and other key government leaders.

4.B Review, evaluate,   ■   Review existing data on cost effectiveness/cost     ■   More policies will be implemented to support
and report cost             savings.                                                effective prevention/treatment interventions
effectiveness/cost      ■   Analyze data on diabetes costs using                    that are cost effective.
savings associated          appropriate methodologies.
with effective
diabetes prevention     ■   Disseminate diabetes cost information to
and treatment               legislators and policy makers.

4.C Convey the          ■   Identify existing evidence for effective diabetes   ■   Increased evidence for effective diabetes self-
impact of diabetes          self-management training and conduct                    management training.
services, including         additional outcomes research to prove the           ■   Increased evidence for effective primary
self-management             effectiveness of diabetes self-management               prevention interventions.
training, and primary       training.
prevention to                                                                   ■   Increased reimbursement for diabetes
                        ■   Identify existing evidence for primary                  self-management training.
legislators and             prevention interventions and conduct
policy makers.              additional research to test effectiveness           ■   Funding established for methods of primary
                            of interventions and facilitate their                   prevention.
                        ■   Request town hall meetings with elected
                            officials to develop strategies for improving
                            federal and state reimbursement for diabetes
                            self-management training and prevention.

4.D Promote             ■   Advocate for funding of research to cure            ■   Increased funding for diabetes research
increased funding for       type 1 diabetes.                                        and programs.
diabetes research       ■   Advocate for funding of statewide and local         ■   Increased variety of funding streams that
and programs.               diabetes treatment and prevention programs.             support diabetes prevention and treatment
                        ■   Formulate budget requests linked to specific            programs.
                            tasks and expected outcomes from the Plan.

                                               Table 4. Guiding Public Policy

Call to Action                                      4. Share data with the California
                                                                    Diabetes Prevention and Control
                                                                    Program to better monitor
                        California’s Plan for Diabetes pro-         diabetes in the state.
                        vides a framework for organizations
                                                                 5. Foster viable collaborations and
                        to mobilize around a single set of
                                                                    partnerships at all levels.
                        common goals: increase access to
                        care, improve the quality of care,       We believe that your action in
                        enhance primary prevention and           addressing diabetes for the next five
                        guide public policy for diabetes.        years will make a notable difference
                        It will take your active involvement     in the lives of those with, or at risk
                        to assure that your community is         for, diabetes in California.
                        addressing priority areas in diabetes.
                        Join us in action by taking the
                        following steps:
                                                                 An idea without a plan is a dream,
                        1. Make a commitment and become
                           a partner with others in your com-    but an idea with a plan promotes
                           munity and with the California        action. California’s Plan for Diabetes
                           Diabetes Prevention and Control       is the basis for organizations
                           Program in addressing diabetes.       throughout the state to coordinate
                                                                 their efforts in diabetes around
        “Numbers will give us power to                           common goals. Diabetes is a huge
                                                                 and growing problem that cannot
     prove that we need to have programs                         be solved by a single group. The
        in specific areas. We need to all                        Plan should help organizations and
                                                                 communities identify needs, set
            work on collecting data.”                            priorities, and develop objectives
                        2. Conduct interventions that best       that can be accomplished. The sum
                           meet the needs of your community.     of these coordinated parts will add
                           Use the Plan to guide intervention    up to better results in addressing
                           choices.                              diabetes in California.
                        3. Communicate your work in dia-
                           betes by sharing your challenges
                           and successes with the California
                           Diabetes Prevention and Control
                           Program and its partners.

References                                             ADA The Expert Committee on

                                                   the Diagnosis and Classification of
                                                   Diabetes Mellitus: Report of the Expert
     1   Okie, S. ‘Pre-diabetes’ tests urged for   Committee on the Diagnosis and
     overweight Americans. Washington              Classification of Diabetes Mellitus.
     Post. 3/28/02:A08.                            Diabetes Care, 26:S103, 2003.
     2   Data from the California Diabetes         9   Data from American Diabetes
     Prevention and Control Program:               Association: Basic diabetes information.
     Diabetes Data for California: Prevalence      [
     and Risk Factors. California                  application/commercewf?origin=
     Department of Health Services.                *.jsp&event=link(B)]
     1997. p. iv.
                                                   10   Data from Healthy People 2010.
     3   Data from the California Diabetes         Leading health indicators: overweight
     Prevention and Control Program:               and obesity.
     Overview of Diabetes in California.           [
     2002. p.1.                                    document/html/uih/uih_4.htm#over
     4   Data from the California Diabetes         andobese]

     Prevention and Control Program:               11   Data from Centers for Disease
     Overview of Diabetes in California.           Control, National Center for Health
     2002. p.1.                                    Statistics. Prevalence of overweight
     5   Data from Centers for Disease             among children and adolescents: United

     Control: National Center for Health           States, 2000.

     Statistics. National Vital Statistics         [

     Report, Vol. 50 (16), September 16,           pubs/pubd/hestats/overwght99.htm]

     2002. p.8.                                    12   Data from American Diabetes
     6   Data from Centers for Disease             Association: Children and diabetes.

     Control. Diabetes: Disabling, Deadly          [

     and on the Rise. 2002. p.2.                   application/commercewf?origin=*.js
     7   Data from the California Diabetes
     Prevention and Control Program:
                                                   13   Data from American Diabetes

     Overview of Diabetes in California.           Association: Pre-diabetes.

     2002. p.1.                                    [

Glossary                                 California Health Interview
                                              Survey (CHIS): CHIS is the largest
                                              state health survey conducted in
                                                                                        Healthy People 2010: A set of
                                                                                        national health objectives designed
                                                                                        to identify the most significant
     Coordinated care delivery model:
                                              the United States. The first survey—      preventable threats to health, and
     A model of care that integrates
                                              CHIS 2001—collected information           to establish national goals to reduce
     different components of the health
                                              from 73,821 individuals: 55,428           these threats. The objectives are
     care system, such as the providers,
                                              adults, 5,801 adolescents and             administered through the U.S.
     community, and the patient, into
                                              12,592 parents about a child. CHIS        Department of Health and Human
     an integrated method of monitoring
                                              collects information on important         Services and can be found at
     and managing patient care. One of
                                              health conditions such as diabetes,
     the most well known examples is
                                              cancer, and asthma. CHIS will bene-       healthypeople/default.htm.
     the Chronic Care Model developed
                                              fit the health and health care needs
     by Ed Wagner and colleagues.                                                       Health Plan Employer Data and
                                              of California’s ethnically diverse
     Additional information about the                                                   Information Set (HEDIS): HEDIS
                                              population since it is enhanced by
     Chronic Care Model is available at                                                 is a set of standardized performance
                                              cultural adaptation and translation                                               measures designed to ensure that
                                              in six languages: English, Spanish,
     change/model/components.html.                                                      purchasers and consumers have the
                                              Chinese, Vietnamese, Korean and
                                                                                        information they need to reliably
     Behavioral Risk Factor                   Khmer (Cambodian) and includes
                                                                                        compare the performance of managed
     Surveillance System (BRFSS):             large samples of African Americans,
                                                                                        health care plans. The performance
     In California, this state-administered   American Indians and Alaska Natives,
                                                                                        measures in HEDIS are related to
     telephone survey is part of the          Asian Americans and Pacific Islanders
                                                                                        many significant public health issues
     surveillance effort conducted by         and Latinos. CHIS will survey the
                                                                                        such as diabetes, cancer, heart
     the California Department of Health      state’s population every two years.
                                                                                        disease, asthma, and smoking.
     Services and the Public Health
                                              Gestational Diabetes Mellitus             HEDIS also includes a standardized
     Institute in cooperation with the
                                              (GDM): GDM is defined as any              survey of consumers’ experiences
     Centers for Disease Control and
                                              degree of glucose intolerance with        that evaluates plan performance
     Prevention. The emphasis of this sur-
                                              onset or first recognition during preg-   in areas such as customer service,
     vey is on health-related behaviors in
                                              nancy. The definition applies whether     access to care and claims processing.
     the adult population with a specific
                                              insulin or diet-only modification is      HEDIS is sponsored, supported
     focus on behaviors related to disease
                                              used for treatment, and whether           and maintained by the National
     and injury. The survey has been
                                              or not the condition persists after       Committee for Quality Assurance
     ongoing in California since January
                                              pregnancy. It does not exclude the        (NCQA).
     1984. The annual sample size for
                                              possibility that unrecognized glucose
     this survey is approximately 4,000
                                              intolerance may have pre-existed or
                                              may have begun during pregnancy.

Impaired Fasting Glucose (IFG):           areas for the
IFG is also known as “pre-diabetes.”      national diabetes
IFG occurs when the fasting plasma        program:
glucose value is 110-125 mg/dL.           (1) establish
These glucose values are greater than     measurement
the level considered normal but less      procedures to
than the level (126 mg/dL) that is        track program
diagnostic of diabetes.                   success in reach-
                                          ing National
Impaired Glucose Tolerance
                                          Objectives; (2)
(IGT): IGT is also known as
                                          demonstrate suc-
“pre-diabetes.” IGT occurs when the
                                          cess in achieving
blood glucose level is higher than
                                          an increase in
normal, but not high enough to be
                                          the percentage
classified as diabetes. IGT is indicat-
                                          of persons with
ed by a blood glucose level of 140-
                                          diabetes in your
199 mg/dl two hours after drinking
                                          state or jurisdic-
the glucose solution in the oral
                                          tion who receive the recommended         (7) demonstrate success in establish-
glucose tolerance test (OGTT).
                                          foot exams; (3) demonstrate success      ing useful programs for the promo-
Individual Practice Association           in achieving an increase in the per-     tion of wellness, physical activity,
(IPA): A network of individual            centage of persons with diabetes in      weight and blood pressure control,
physicians or physicians in smaller       your state or jurisdiction who           and smoking cessation for persons
groups. IPAs contract with individual     receive the recommended eye              with diabetes.
physicians who see HMO members            exams; (4) demonstrate success in
                                                                                   Obesity: Obesity is defined as an
as well as patients covered by other      achieving an increase in the percent-
                                                                                   excessively high amount of body fat
types of health insurance in their        age of persons with diabetes in your
                                                                                   or adipose tissue in relation to lean
own private offices. Physicians in an     state or jurisdiction who receive the
                                                                                   body mass. The amount of body fat
IPA are paid on either a capitation or    recommended influenza and pneu-
                                                                                   (or adiposity) includes concern for
a modified fee-for-service basis.         mococcal vaccines; (5) demonstrate
                                                                                   both the distribution of fat through-
                                          success in achieving an increase
National Diabetes Objectives: In                                                   out the body and the size of the
                                          in the percentage of persons with
1999, the Division of Diabetes                                                     adipose tissue depots. Individuals
                                          diabetes in your state or jurisdiction
Translation (DDT) at the Centers for                                               with a Body Mass Index (BMI)
                                          who receive the recommended A1C
Disease Control and Prevention,                                                    of 30 or more are considered obese.
                                          tests; (6) demonstrate success in
established the following seven                                          
                                          reducing health disparities for
DDT National Objectives as priority                                                obesity/defining.htm
                                          high risk populations and;

Overweight: Overweight refers to        diabetes within 10 years, but this         Secondary Prevention: Testing and
increased body weight in relation to    can be minimized through healthy           treating people with an established
height, when compared to some           eating and physical activity.              disease in order to prevent recurrent
standard of acceptable or desirable                                                events or disease progression.
                                        Prevalence: The proportion of per-
weight. Individuals with a BMI of
                                        sons with a particular disease within      Type 1 Diabetes: Type 1 diabetes,
25 to 29.9 are considered overweight.
                                        a given population at a given time.        previously known as juvenile
                                                                                   diabetes, is usually diagnosed in
obesity/defining.htm                    Primary Prevention: Include
                                                                                   children and young adults. In type 1
                                        efforts that protect individuals
Preferred Provider Organization                                                    diabetes, the body does not produce
                                        against disease, and are aimed
(PPO): Some combination of hospi-                                                  enough insulin due to autoimmune
                                        at keeping a population healthy.
tals and physicians agree to provide                                               destruction of the insulin producing
health care services to a group of      Risk Assessment: A planned pro-            beta cells in the pancreas.
people, perhaps under contract with     gram to identify those at risk for a
                                                                                   Type 2 Diabetes: Type 2 diabetes
a private insurer. The services may     disease by assessing their risk factors.
                                                                                   is a metabolic disorder resulting
be furnished at discounted rates.       For diabetes, the American Diabetes
                                                                                   from the body’s inability to make
Patients may incur expenses for         Association has a Risk Test (a paper
                                                                                   enough, or properly use, insulin.
covered services they receive outside   risk assessment tool) to identify
                                                                                   Type 2 diabetes is the most common
the PPO, if the charge from the         high-risk individuals (www.dia-
                                                                                   form of diabetes.
non-PPO provider exceeds the   Persons identified to be
PPO reimbursement rate.                 at high-risk should be referred for
                                        diagnostic testing.
Pre-diabetes: Pre-diabetes is the
state that occurs when a person’s       Screening/ Diagnostic Testing
blood glucose levels are higher than    for Diabetes: Involves checking
normal, but not high enough for a       an individual’s blood glucose level
diagnosis of type 2 diabetes. This is   in a medical setting to confirm the
also referred to as Impaired Glucose    presence or absence of diabetes.
Tolerance or Impaired Fasting           If using finger stick testing in a
Glucose, depending upon whether         screening program, there must be
an oral glucose tolerance test or a     a means of referring individuals
fasting blood glucose test was used.    with a positive test for follow-up
People with pre-diabetes have a         care. Finger stick testing requires
1 in 3 chance of developing type 2      licensure for laboratory testing.

Resources                                           California HealthCare
                     The following resources may be
                     useful to organizations seeking         Centers for Disease Control
                     additional information about dia-       and Prevention
                     betes. Some of the resources also
                     provide funding to selected agencies.
                                                             Health Disparities Collaborative
                     Please contact the organization
                     directly for additional information.
                                                             Improving Chronic Illness
                     American Diabetes Association
                                                             Care Program
                     California Diabetes
                                                             Integrated Health Care
                     and Pregnancy Program
                                                             Juvenile Diabetes Research
 “The landscape of diabetes is changing            

for the better. But we’ve got a long way                     National Committee
                                                             for Quality Assurance
 to go and we must keep working at it.
       Every person is important.”
                                                             National Diabetes Education
                     California Diabetes Prevention
                     and Control Program                     Robert Wood Johnson
                     The California Endowment

     Individuals from the following organizations contributed significant time and energy to the development
                of California’s Plan for Diabetes. Their feedback and support is great appreciated.

                                 Alameda County Health Care Services Agency
                                         American Diabetes Association
                         Association of Asian Pacific Community Health Organizations
                              California Diabetes Prevention and Control Program
                           CMRI - The California Quality Improvement Organization
                                       California Primary Care Association
                                 Community Health Councils, Inc. REACH 2010
                                         Diabetes Coalition of California
                                                   Health Net
                                                  Lifescan, Inc.
                                                  Project Dulce

                                                Special thanks to:
                                  Hull + Honeycutt Marketing and Design, Inc.,
                            who donated graphic design and layout services and the
                                        Diabetes Coalition of California,
                                      who funded the printing of the Plan.

            NAS Consulting and Samuels and Associates provided technical assistance for this project.
                              Photography © Susie Fitzhugh, Seattle, Washington.

                          We want to hear from you!
                        Tell us what you think of California’s Plan for Diabetes.
                     Check out our web-based reporting tool. Download valuable
                             diabetes resources. Join our online mailing list.


To gather additional input for the        Hill Physicians Medical Group, Inc.      San Diego State University
Plan, ten community meetings were         Homeys Youth Foundation - California     San Francisco Department
held throughout California and a          Home Instruction Program for Preschool   of Public Health
draft was posted on the California        Youngsters
Diabetes Prevention and Control                                                    San Mateo Community Health Services
Program’s web site. Common                Juvenile Diabetes Research Foundation    Sharp Health Care
themes were included in the Plan          Kaiser Permanente, Los Angeles
from the following organizations:                                                  Sonoma Valley Community
                                          Kaiser Permanente, Northern California   Health Clinic
Alameda Alliance for Health
                                          Latino Community Diabetes Council        Southwest Community Health Center
Alameda County Public Health
Department                                Los Angeles County Area Agency           Stanford Patient Education
                                          on Aging                                 Research Center
American Association of Retired Persons
(AARP)                                    Los Angeles County Department            Stanford University
                                          of Health Services                       St. Mary’s Medical Center
Asian Pacific Health Care Venture
                                          Los Angeles County DHS Children’s        St. Johns Health Center
Aventis Pharmaceuticals
                                          Health Initiatives
Blue Cross of California State                                                     St. Vincent Medical Center
                                          Los Angeles County Office of Education
Sponsored Programs                                                                 St. Vincent Medical Center
                                          Los Angeles Metropolitan Medical         Educational Services
Brookside Community Health Center
Bristol Myers & Squibb                                                             Summit Health Ministry
                                          Los Angeles County + University
California Black Health Network           of Southern California Health Care       Sutter Health Family Practice Center
California Diabetes in Pregnancy          Network (LAC+USC Health Care             Therasense
Program                                   Network)
                                                                                   The Children’s Clinic
California Heart Disease and Stroke       Queen of Angels Hollywood
                                          Presbyterian Medical Center—             The Salvation Army
Prevention Program, Department
of Health Services                        Tenet Health System                      University of Southern California (USC)
                                          National Asian Women’s Health            Advanced Biotelecommunications and
California Hospital Medical Center                                                 Bioinformatics Center (ABBC)
                                          Organization (NAWHO)
California Medical Association                                                     University of Southern California School
                                          Mini Pharmacy
Charles R. Drew University of Science                                              of Policy, Planning, and Development
and Medicine/University of California,    Multicultural Area Health
                                          Education Center                         U.S. Food and Drug Administration,
Los Angeles                                                                        Los Angeles District
Children’s Hospital Oakland               Northern California Center
                                          for Wellbeing                            Ventura County Medical Research
Community Health Partnership                                                       Foundation
                                          Oakland Unified School District
County of San Diego                                                                Ventura County Chronic Disease
                                          Pajaro Valley Community Health Trust     Prevention Partnership
Diabetes Amputation Prevention
Foundation                                Por La Vida                              Ventura County Public Health
Diabetes Society of Sonoma County         Project Concern International            California’s Plan for Diabetes is
                                          Redwood Community Health Coalition       evolving as we continue our work
Disetronic Medical Systems, Inc.
                                                                                   in diabetes. We invite you to partici-
Doheny Retina Institute                   Sansum Medical Research Institute        pate in the implementation of the
Fullerton College Student/PUENTE          Santa Clara County Chapter of            Plan and join the list of supporting
                                          American Association of Diabetes         organizations.
Gardner Family Health Network             Educators (AADE)                         The Plan is available for download
Health Promotion and Binational/Border    Santa Clara County IPA                   at Continue
Health, Health Education Program                                                   to check the web site as updates to
                                          Santa Clara Valley Medical Center
Health Trust                                                                       the Plan are posted.
                                          Diabetes Center
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