Texas: Enhancing diabetes care through personalized, high-touch case management

Brookings, 6 April 2015

The Rio Grande Valley (RGV) Accountable Care Organization (ACO) uses a wide array of strategies to help their patients with diabetes – approximately 45 percent of their patient population – better manage their condition. The diabetes initiatives aim to support patients to understand their disease, undergo lifestyle changes, and systematically employ diabetes management approaches. All practices utilize care coordinators, who reach out to patients with uncontrolled diabetes as often as every other day. In these regular contacts, the care coordinator can check-in with the patient to see how they are doing and make any medication adjustments necessary. Other initiatives include weekly uncontrolled diabetes clinics, where diabetics can see a nutritionist after their provider visit, and a central Diabetes Education Center that provides additional support to practices and their patients. Read more.