The diabetes clinical care management team at Progressive Community Health Centers, which has three locations in Milwaukee, works together to ensure patients have the tools needed to self-manage their diabetes.
The team uses phone calls, individual and group visits and motivational interviewing to understand potential barriers for patients and create links to care, such as transportation, affordable medications, access to food and screening for behavioral health concerns.
As a result, in 2021 Progressive eliminated racial and ethnic disparities in diabetes control (as defined by the Uniform Data System). At the end of the year, 23% of the 1,100 African American patients with diabetes were uncontrolled or without a test compared with 22% of white patients.
The team consists of Francesca Napolitano and Sarah Ray, clinical pharmacists; Pang Vang, registered nurse care coordinator; Marshae Love, medical assistant; Madeline Tully, family physician; Josh Spierer, behavioral health consultant; Jay Schubring, data analyst; Tracy Blohm, medical records; Ellen Ketter, physician assistant; Suzanne Gosenheimer, director of quality management; and Allison Kos, chief medical officer.
