A novel digitally-enabled interdisciplinary diabetes care model at an urban academic medical center: a proposed framework (Preprint)

UNSTRUCTURED Diabetes is one of the most common chronic diseases and is estimated to affect 10.5% of the US population, with less than half of adults have hemoglobin A1c (HbA1c) values below the recommended goal of 7%. Institute of Medicine (IOM) believes that the quality-of-care gap in medicine results from a poorly organized delivery system, care coordination, and constraints in using modern information technology. This is the first article to describe a transformative and novel digitally-enabled diabetes care model at an urban academic medical center that redesigned diabetes care by leveraging digital health tools and team-based care involving nursing, pharmacists, and physicians, leading to significant improvement in clinical, operational, utilization and patient self-care outcomes.