Health Partners of Western Ohio Use Prediabetes Screening to Prevent and Diagnose Diabetes

Health Partners of Western Ohio buildingHealth Partners of Western Ohio HRSA BPHC exit disclaimer (HPWO) is a HRSA Health Center Program grantee, which has 16 health center locations in Western Ohio and provides medical, dental, behavioral health, pharmacy services, and social services. HPWO was designated as a 2018 HRSA Diabetes Leader.

The goal of HPWO’s prediabetes program is to identify high risk patients and offer specific education and interventions to prevent diabetes. The secondary goal is to increase the number of patients referred to and participating in formal Diabetes Prevention Programs.

Through this pilot project with the Ohio Association of Community Health Centers, HPWO developed a workflow to screen all patients over 18 years of age for prediabetes using a screening questionnaire.

Prediabetes Screening Workflow

Clinical alerts in the HPWO Electronic Health Record remind the care team of the need to screen a patient if he/she is over 18, without a previous diagnosis of diabetes or prediabetes and if he/she had not been screened in the last 12 months. A health coach, who is a member of the multidisciplinary team, administers the American Diabetes Association “Are you at risk for type 2 diabetes?” questionnaire to the patient.

All scores from this questionnaire are documented in the patients’ Diabetes Risk Flowsheet which is date stamped with the value. The health coach notifies the clinical care team if the patient’s screening score is >5, so that a diabetes screening blood test can be completed during that visit (A1C, glucose, etc.). After further evaluation, the provider may diagnose the patient with prediabetes or diabetes, and provide the appropriate treatment. All patients who receive the screening questionnaire are educated about risk factors and recommended lifestyle changes that were identified during the screening, regardless of the final score.

Patients with prediabetes are referred to the health center’s internal diabetes prevention program and lifestyle coach who teaches DPP class content using CDC’s Prevent T2 curriculum. Lifestyle coaches follow up with patients who have diabetes risk factors but haven’t enrolled in the education program.


HPWO piloted the workflow at one site to expand population screening and to develop a formal Diabetes Prevention Program group education class. The pilot demonstrated that expanded screening was feasible within the workflow, and it identified a large population of patients as high risk that would have not been formally screened in the past. The health center spread the screening and prevention program to all clinical sites within a few months. During a single quarter, HPWO screened 3,551 patients for prediabetes. Of those screened, 1,905 were identified as high risk for prediabetes or diabetes and 208 of them were diagnosed with prediabetes with a confirmatory blood test. Nineteen individuals were diagnosed with diabetes. HPWO believes earlier diagnoses have led to easier diabetes management and less patients with uncontrolled diabetes.

How to Implement

  • Develop alerts that will scan a patient’s chart and create a flag for anyone who meets the ADA screening criteria.
  • Identify and train health coaches or other personnel to administer the questionnaire to patients during intake for a visit.
  • Identify and train a diabetes prevention program coordinator to support patients with prediabetes and offer a Diabetes Prevention Program.
  • Implement the Diabetes Prevention Program with one-on-one support and group classes about nutrition, lifestyle changes, and patient adherence tools.
Date Last Reviewed:  February 2019

More Information

Health center's Uniform Data System (UDS) data

HPWO Prediabetes Screening Workflow and Questionnaire (PDF - 365 KB)

For more information about this promising practice, contact:
Dr. Jennifer Clark, Chief Population Health Officer