Underserved populations are at higher risk of developing diabetes-related complications. This study aimed to evaluate changes in A1c among undeserved patients who received care through a hybrid Chronic Care Model (h-CCM).

This was a retrospective observational study conducted in two satellite clinics of a federally qualified health center. h-CCM was delivered collaboratively via in-person and telehealth visits conducted by family physicians, nurse practitioners and clinical pharmacists. Baseline sociodemographic of patients >40 years old with diabetes who received care through h-CCM for ≥ 3 months between Oct 2020 and Nov 2022 were included. Patients with any missing data were excluded. Descriptive analysis and paired t-test were used accordingly.

A total of 104 (53.0%) patients were analyzed. The average age was 60.7± 9.8 years with the majority being Hispanic (72.1%), female (57.7%) and with a mean h-CCM visits of 2.2± 1.8 over 3 months. The average ASCVD risk at baseline was 20.0± 16.6% with hypertension (88.5%) being the most common comorbidity. Average A1c decreased from 9.4± 2.1% at baseline to 8.7±1.9 at 3 months (-0.7%, p <0.001) with improvements observed in all levels of baseline A1c (p<0.001, Figure 1).

h-CMM was effective in achieving timely A1c reduction among underserved patients with diabetes. Greater improvements were observed in patients with higher baseline A1c.


J. Y. Lee: None. J. T. Nguyen: None. M. Seo: None. T. Nguyen: None. N. Patel: None. V. Rodriguez: None. J. Mayorga: None.

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