IMPROVING DIABETES CARE FOR UNDERSERVED COMMUNITIES IN PORTLAND, OR
Providence Health and Services works to improve care, reduce health disparities, and strengthen coordination between clinical and social services at three local clinics that serve many low-income individuals with diabetes.
The program identifies gaps in care and then deploys multidisciplinary teams to address them. Three pilot clinics embed full-time community resource specialists who are multilingual and multicultural; they are also trained in motivational interviewing and trauma-informed care to provide referrals to local resources, social services, and benefit programs. In addition, the organization conducts outreach to community residents who are at risk of diabetes or may have unmet diabetes-related health needs.