Innovation Challenge Blog

Innovation Challenge Finalist n4a Diabetes Care Center is Using Big Data to Improve Diabetes Care

n4a Diabetes Care Center is a collaboration of the National Association of Area Agencies on Aging (n4a) and the National Minority Quality Forum. Its mission is to identify people living with diabetes who are under-consuming medical products and services and to help them manage the disease and avoid preventable hospitalizations. The Center will aim to accomplish this objective through precision disease management—targeting those whose inadequate management of their disease places them at immediate risk for a health crisis that requires inpatient care or an emergency room visit.

If you’re a person living with diabetes, you’re probably already well aware that disease management is difficult, but people who don’t have the disease can be quick with giving advice. They might say that blood sugar management is simply about willpower – give up the foods you’ve enjoyed all your life, exercise at least an hour every day, stay on your medicines, attend diabetes education courses, monitor your blood glucose daily, visit your doctor and have your A1C testfour times a year, and do not forget your yearly eye-and-foot exams. Yet it can’t be so simple; the American Diabetes Association notes that only 12% of people living with diabetes are fully compliant with its recommended standards of care.[1]

Some people with diabetes may make all of the necessary life changes on their own. Others appreciate the seriousness of their situation, and may want to reinvent themselves, but are faced with obstacles that stand in their way. They prioritize work over health, they have pressing family obligations, they have do not have a supportive environment, they lack the transportation to visit their physician, or perhaps they just need the energy of a group to help make those difficult changes.

The United States is confronting a diabetes epidemic, and the numbers are troubling. At present, 28 million people are struggling with this disease, and that the number may rise to 35 million by 2030.[2] The American Diabetes Association’s estimate of 12% compliance translates to about 25 million people with diabetes today who are taking unnecessary chances with their health.[3] Currently, people with diabetes have over 14 million hospital encounters (inpatient and outpatient care) each year.[4] Many communities have no diabetes treatment center, and people with diabetes must travel to facilities outside their communities at distances and hours that are not convenient.

The Diabetes Care Center is an in-community program, designed to serve the needs of residents close to their homes. n4a has been providing social services to seniors in every community throughout the US for over forty years, and now plans to use its knowledge and experience to help  people with diabetes of all ages. Through working with the National Minority Quality Forum, The Diabetes Care Center will draw on algorithms that identify people with diabetes, whose low consumption of medical products and services put them at immediate risk for a hospital encounter. From these algorithms, The Center will present patient profiles to physicians, encouraging them to recommend that high-risk patients enroll in a Diabetes Care Center in their neighborhood.

At the Diabetes Care Center, patients will take part in an interview process to identify challenges that interfere with management of their disease. The Center will design a personalized disease-management program for each patient to address his or her personal challenges, and will work with the patient to ensure commitment to the program and its implementation. Powered by the National Minority Quality Forum’s predictive tools, n4a will be in the community, close at hand, to provide the support, encouragement, and infrastructure to reduce acute events, lower the cost of care, and achieve better outcomes for those living with the disease.

About the Author
Gary Puckrein is the President and CEO of the National Minority Quality Forum.

[1] American Diabetes Association, Standard of Medical Care in Diabetes–2010, DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010, pg. S47;

[2] Elbert S. Huang, Anirban Basu, Michael O’Grady, and James C. Capretta, Projecting the Future Diabetes Population Size and Related Costs for the U.S., Diabetes Care December 2009 32:2225-2229;

[3] 88% of 28 million is 25% (the remaining 12% [see note above] fully compliant according to ADA guidelines)

[4] US Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project on hospitalizations (Nationwide Inpatient Sample, 2000 through 2008) and emergency-room visits (Nationwide Emergency Department Sample, 2006 through 2008) by adult patients with diabetes. Diagnosed and undiagnosed diabetes prevalence based on data from the US Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System and National Health and Nutrition Examination Survey.