Fragmented care with limited access to specialized diabetes care and self-management education programs and a suboptimal referral system account for the high prevalence of poorly controlled diabetes in academic health systems. In the Emory Healthcare System, the largest health system in Georgia with over 65,000 patients with DM, ∼15-20% of patients have HbA1c >9%. We implemented the Emory Diabetes Management Program (DMP), a chronic care management model that proactively invited patients with HbA1c >9% scheduled to attend an ambulatory clinic to be seen by a Diabetes Educator/Nurse Practitioner team supervised by an endocrinologist.

Among 898 patients scheduled from 01/01/18 to 11/30/2018, 630 (70.2%) patients attended the program (age 56.2 years, females 62%, African-Americans 73%) with a baseline HbA1c of 10.4±2.0%. The intervention resulted in significant reduction in HbA1c levels and higher number of patients achieving HbA1c <9% compared to patients who did not attend the intervention. In addition, more patients in the intervention achieved an LDL < 100 mg/dl and a blood pressure goal <130/80 mm HG (Table 1).

The Emory-DMP, a proactive chronic care model of focused diabetes education and management, is an effective approach for improving care of patients with diabetes, resulting in significant improvement in HbA1c, blood pressure and lipid control.


A. Ayanambakkam Nambi: None. Z.T. Smith: None. M.S. Presswood: None. S. Jacobs: None. A.F. McAleer: None. P.A. Castellano: Advisory Panel; Self; Vizient. M. Khosravanipour: None. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. F.E. Turton: None. J. Dee: None. C.M. Masi: None. G.J. Esper: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at