The Diabetes Collaborative Care Team has been a great experience, working closely with patients, primary care, and endocrine specialists.  The frequent follow up has helped coordinate care faster and more comprehensively than could otherwise be done. This program is uniquely structured to facilitate care.  

I am part of a model of care that is truly patient centered and seamlessly integrates social and medical needs. I am inspired by the collegiality, mutual support and respect between team members.

With the support of our dedicated team, I feel empowered in assisting our patients to enhance their management of diabetes. I am grateful for the opportunity to engage in the journeys of those we serve, exploring what it means for individuals to live a happy and healthy life. By offering tailored interventions aligned with their personal goals, we play a pivotal role in their health narrative.

Providing concrete, timely, community-based solutions to social drivers of health is one of the more rewarding aspects. As they transition to health coaching several months later, I am impressed by their progress toward their goals, as well as how our collaborative team approach has cultivated such a sustained level of engagement.

In November 2022, the Office of Population Health at UCSF launched the Diabetes Collaborative Care (DCC) program, an innovative diabetes program adapted from the collaborative care model. The model integrates the expertise of specialty care into a nurse-led interdisciplinary team that provides high contact behavioral case management while streamlining a collaborative process between primary and specialty care. Enrolled patients meet weekly with a nurse for individual health coaching, education, linkage to services, and care coordination; patients are presented weekly at case conferences to the Endocrinology partners who make recommendations to the patients’ PCPs and provide guidance for the nurse.

The team took a health equity first approach in identifying patients for enrollment within a managed insurance plan. Prior to launching, the team worked to develop tools for patient identification and management, which included setting inclusion and exclusion criteria, defining roles and responsibilities, and developing patient education material.

The DCC has also focused on providing culturally sensitive, patient-centered care. Some strategies have been verifying that the education material developed is at a 6th- 8th grade reading level; translating the material into other languages; accommodating patient visits after business hours; offering telephone or Zoom visits based on patients’ preferences; and aligning patients with language concordant staff.