Axis Community Health Uses Medical Assistants to Help Manage Diabetes

Mariela Gudino, Axis Medical Assistant 1

"Mariela Gudino, Axis Medical Assistant 1, screens a patient for diabetic retinopathy"

Axis Community Health HRSA BPHC exit disclaimer serves Alameda County, CA. Over half of their patients are Spanish speaking.

They see higher rates of patients with multiple health problems and chronic illnesses within an aging population.

Axis has a quality goal of an HbA1c level of less than 8%. They received an FY 2019 National Quality Leader award in Diabetes Health.


Axis focuses on health maintenance for all patients to help fill gaps in care. They use pre-visit planning and medical assistants to carry out services. This is how they succeed at managing diabetes and other chronic conditions.

Medical Assistant Role

Axis underwent a care team transformation in 2014, using the Institute for Healthcare Improvement HRSA BPHC exit disclaimer care team model. The goal is for everyone to practice at the top of their licensure to improve job satisfaction and efficiency.

  • Axis established three achievement levels for Medical Assistants (MAs) with added responsibility at each level.
  • Level 3 MAs conduct pre-visit planning to support diabetes care management, which includes:
    • Review charts daily before appointments to look for gaps in care and overdue procedures
    • Enter standing orders and do pre-charting to help providers have efficient visits
    • Meet with providers in huddles every morning or afternoon before clinic times to review upcoming patient appointments.
  • MAs receive regular training to develop knowledge of workflows, the EHR system, data analysis, and motivational interviewing.

Retinal Scan Clinics

To better care for patients with diabetes, Axis offers regular retinal scans that MAs coordinate.

  • They offer on-site retinal screening two days a week.
  • The California Healthcare Foundation provided a camera via a grant.
  • Axis contracts with University of California, Berkeley, Ophthalmology to read the images.
  • An Axis MA does the retinal scan. They also refer patients to outside ophthalmology, when needed.


  • The new pre-visit planning has saved time for providers and improved patients’ health maintenance.
  • Provider and staff satisfaction improved from a score of 3.5 to 4 (out of 5). Some MAs left for higher paying jobs, but returned to participate more in the patient’s care.
  • Patient satisfaction improved from a score of 3.5 to 4.5 (out of 5).
  • About 800 diabetic patients receive retinal screening yearly.
Date Last Reviewed:  November 2019

More Information

Health center's Uniform Data System (UDS) data

For more information about this promising practice, contact:
Amit Pabla, Chief Quality & Transformation Officer