Improving Patient Outcomes: A 3-Part Guide to Closing Clinical Care Gaps (Part 3: Diabetes)


Part Three: Patients with Diabetes

Editor’s note: This is the third article in a three-part series. Be sure to read part one (COPD) and part two (hypertension).

More than 1 in 10 individuals in the U.S. (about 37 million people) have diabetes, according to the Centers for Disease Control and Prevention (CDC). What’s worse is that the CDC estimates 8.5 million people have the disease and don’t even know it. This dangerous and potentially life-threatening condition costs $237 billion in direct medical costs and $90 billion in lost productivity. The following are ways in which clinical teams can help close care gaps and provide value-based care for patients with diabetes:

Utilize technology to identify individuals with diabetes. When it comes to diabetes, it is crucial to identify patients at risk of developing the condition or those who already have it. A highly effective approach is to employ point-of-care gap flags that prompt healthcare professionals to regularly screen for diabetes using various tests. These tests not only help confirm the presence of prediabetes, a serious health condition characterized by higher-than-normal blood sugar levels that do not meet the criteria for a type 2 diabetes diagnosis but also assist in identifying individuals at risk. Technology not only aids in the early identification of individuals at risk of diabetes but also empowers patients and healthcare providers to proactively manage the condition effectively.

Enroll patients in care management programs such as chronic care management (CCM). Patients with diabetes can often have many other complications such as nephropathy, retinopathy, neuropathy, cardiovascular disease, stroke, and even death. Providers can delay or prevent many of these complications by enrolling patients in a CCM program and helping them manage their disease effectively. An individualized treatment plan incorporates access to community resources, a proactive approach to chronic disease management, and care coordination among providers. Clinicians also promote optimal health through nutrition therapy and monitoring, suggestions for physical activity, and goal setting.

Follow clinical guidelines and best practices for diabetes. The latest clinical guidelines from the American Diabetes Association promote higher weight loss (up to 15%), recommendations for sleep health and physical activity, broad consideration of social determinants of health, lipid management recommendations, point-of-care A1C testing, and much more.


Focus on diabetes self-management education. Self-management is an ongoing process that changes as patients’ needs, priorities, and situations change. CCM programs can help patients understand treatment options; implement healthy eating and physical activity; prevent, detect, and treat acute and chronic complications; and cope with psychosocial issues and concerns. The frequent touchpoints inherent in CCM programs make it easier to provide ongoing education and support annually for health maintenance, when new complicating factors influence self-management, and when transitions in care occur.


Leveraging point-of-care gap flags to identify patients with diabetes and those who are at risk of developing the disease enables healthcare providers to empower patients and improve their quality of life. Closing clinical care gaps for patients with diabetes requires a multi-disciplinary team approach that promotes patient education and empowerment. CCM programs can facilitate ongoing communication and make this approach possible. Contact DignifiHealth to learn how we can assist you in closing clinical care gaps.