Connecting Diabetes Care from the Clinic to the Community


BY JOHNNA REED, vice president, business development, Bon Secours Health System

In 2011, the Bon Secours St. Francis Health System in Greenville, South Carolina created a Diabetes Integrated Practice Unit (IPU) to foster a new environment that improves the health of patients with, or at risk of developing, type 2 diabetes.

Since most of the factors that influence health exist outside of the doctor’s office, we’ve learned the importance of connecting our patients to resources in their communities. This helps them in their daily lives and better supports their ongoing medical care.

The goal of the Diabetes IPU is to connect patients with community resources that can help benefit their health through improved nutrition, increased physical activity and support to manage their condition. The program also ensures that physicians and other caregivers have sufficient time to focus on their patient’s needed care. This added time also allows providers and patients to work together to understand how obesity, prediabetes and diabetes can affect health and daily life and to set goals that work for each patient’s unique circumstances. 

The program also emphasizes the importance of prevention, to avoid developing additional health risks or problems in the future. We help prediabetics avoid the progression to diabetes and help diabetics avoid developing additional conditions.

The program is designed around a network of community and clinical resources, providers and technology. While the program hub is at St. Francis Millennium, the programs themselves are delivered where patients are—at work, home, and throughout the community.

The Diabetes IPU includes an extensive coordinated team of care givers, including a primary care physician, ophthalmology, cardiology, nephrology and podiatry services, and an endocrinologist who consults with the primary care physicians regarding innovations in diabetes care and assists with the care of patients facing particular medical challenges.

The medical care is managed by a registered nurse care coordinator. It’s also important to note that our care team includes a psychologist, social worker, registered dietician, diabetes educator, pharmacist, and an exercise physiologist to help patients get to a healthy weight. It is not just a clinicalcentered approach — it’s a total community health approach.


A patient’s initial visit with the diabetes team begins with a fasting blood draw to determine blood glucose, HbA1c, cholesterol, and other relevant lab values. Following the blood draw, patients are provided a diabetes-appropriate breakfast. Next, the patient is asked to participate in a small group discussion about issues they have in dealing with diabetes, led by a diabetes educator and nurse. Facilitators are continually surprised at the level of engagement in these groups — patients tend to share readily and openly.

The group discussion not only introduces patients to others who share similar health and lifestyle challenges—including being overweight or obese and struggling to engage in physical activity and eat healthy—but also enables the nurse facilitator to determine the best match for the patient with individual caregivers. After the discussion, the entire group receives an introduction to exercise with an exercise physiologist who provides an easy, low stress overview of exercise options.

In the course of this first morning, the patient sees the primary physician, psychologist, diabetes educator, and registered dietitian. Each patient also receives a retinal scan and foot exam. Finally, patients are served a diabetes friendly lunch with the clinical team present to answer questions about the food or anything else related to diabetes.

However, our work doesn’t stop when the patient leaves the clinic. Because the needs of patients with type 2 diabetes require support and resources in the community, our diabetes program provides worksite and home services. After their visit, a team member meets with patients in their home to assess the support network available and to identify areas where patients will face particular challenges. Our teams then work with family and employers to inform and facilitate improvements in the home and work environments and sometimes in the local grocery stores and pharmacies.

Often, the care team conducts a thorough workplace assessment to determine how each patient’s work setting impacts his or her health. For example, if there is no access to healthy foods, we work with the employer to improve the food options at a worksite. It might be surprising that employers have been incredibly supportive, however they fully understand the importance of having a healthy, happy, and productive workforce.

From the patient perspective, the most important measure is improvement in the ability to live (i.e., to work, participate in family life, attend important events, and enjoy daily activities). With each patient, the care team identifies capabilities that are motivating and meaningful and track their improvement. While these measures require greater effort to quantify, they are often the drivers of people’s long-term commitment to lifestyle change and health.

Patients have responded incredibly well. A recent patient entered the program hoping to improve his health, get off regular insulin and lose about 60 lbs. With the diabetes team’s help, he understood the need to deny barriers and stressors, such as fast food and sugary drinks, and was very successful.

Through the program, he increased glucose monitoring from to three to four times daily; went from not exercising at all to exercising four times a week at the facility we recommended to him; attended all prescribed education opportunities and shared medical group appointments; and engaged often with our dietician. While he hasn’t yet reached all his top-level goals, he lost more than 45 lbs., reduced his BMI from 33.7 to 27.5 and his waist size from 44 to 36, and no longer needs mealtime insulin coverage.

The most successful patients are the ones who receive a continuum of care from the clinic to their community. Our model improves a physician’s capability by bringing all of the necessary community resources together. Research shows that what happens outside the doctor’s office can have a major impact—either positive or negative—on our health. That’s why we began the Diabetes IPU model and why we’ll continue using it to fight obesity and improve the care of individuals with prediabetes or diabetes.