IMPACT-DM: Improving Management of Poorly Controlled Type 2 Diabetes (A1c ≥9%) Through Coordinated, Team-Based Care...

Uncontrolled type 2 diabetes disproportionately affects underserved populations and contributes to substantial morbidity, mortality, and healthcare costs. In Federally Qualified Health Centers (FQHCs), infrequent follow-up and inconsistent use of real-time glycemic data limit timely treatment intensification. In a multi-site FQHC serving underserved communities, baseline data demonstrated persistently high rates of uncontrolled diabetes (A1c ≥9%) despite access to in-house point-of-care A1c testing. Provider-dependent workflows, inconsistent follow-up, and low patient engagement were identified as key barriers to sustained glycemic control.ObjectiveTo evaluate the impact of a monthly, interprofessional follow-up model incorporating medical assistant (MA)-led point-of-care A1c testing and clinical pharmacy integration on glycemic control and cardiometabolic outcomes in an FQHC setting.MethodsA 12-month quality improvement initiative using the Plan-Do-Study-Act framework was implemented across multiple FQHC sites. Adults with type 2 diabetes and A1c ≥9% were enrolled. The primary outcome was the inverse diabetes quality measure (A1c ≥9%). Secondary outcomes included A1c distribution, provider-level A1c improvement, blood pressure control (<130/80 mmHg), and LDL cholesterol control (<100 mg/dL).ResultsAn initial four-month pilot cohort of 138 patients with A1c ≥9%, managed by two primary care providers, demonstrated rapid glycemic improvement, with 81.8% achieving A1c <9%. These findings informed workflow refinement and organization-wide implementation over the subsequent year, during which the inverse diabetes quality measure improved from 24.1% to 18.6% (absolute reduction of 5.5 percentage points). Concurrent improvements were observed in blood pressure control (36.0% to 40.6%) and LDL cholesterol control (45.0% to 47.0%).ConclusionsA monthly interprofessional follow-up model with MA-led in-house A1c testing and clinical pharmacy integration was associated with improved glycemic and cardiometabolic outcomes in an FQHC setting. This scalable approach supports value-based chronic disease management in underserved populations.