Harrisonburg Community Health Center Uses Action Planning to Improve Diabetes Measures

Vanessa Yoder, RN

"Vanessa Yoder, RN, meets with a patient"

Harrisonburg Community Health Center, Inc. (HCHC) serves patients in the city of Harrisonburg and Rockingham County, VA.

About 91% of their patients are below 200% of the federal poverty level (FPL). About 56% of patients are below 100% of the FPL.

Their patients include members from an immigrant resettlement community, and 36% speaks a language other than English as their primary language.

HCHC sees many cultural influences with regard to diet and health.


HCHC believed they were doing all they could about diabetes until they analyzed their data. In 2018, they had a diabetes targeted technical assistance (TA) site visit. They worked with experts to develop a diabetes action plan.

Action Plan

First, they identified challenges that impact their diabetes program:

  • The number of patients at the health center doubled in a short period. This doubled the number of patients diagnosed with diabetes. Most new patients have uncontrolled diabetes.
  • Many non-English speaking patients had problems using public transportation. This caused them to miss appointments.
  • They experienced high staff turnover of diabetes educators, and none were bilingual.

Next, they identified three action steps for the next year:

  • Care Coordinators:  Focus on bringing patients back. When patients returned, their diabetes was often uncontrolled. Patients began weekly food diaries and biweekly check-in calls. Through the check-in calls, coordinators identify issues every two weeks instead of at quarterly Diabetes Management provider visits.
  • Diabetes Nurse Educators:  Hire diabetes nurse educators who speak multiple languages. High turnover was a challenge, but they worked with the local hospital’s diabetes education program. These nurses establish patient trust, so they can discuss cultural challenges in managing diabetes.
  • Provider Engagement:  Increase provider engagement with best practices and identify a provider champion. The champion engages the provider team on how to improve and standardize diabetes management. They created provider dashboards, which display monthly patient data on several measures. All provider data is visible, so providers with good data can support others.

Outcomes and Data

  • HCHC’s uncontrolled or untested A1C measure was at 39% and went to 31% within a year of implementing this program. (The health center program national average is 32% uncontrolled.)
  • Patients report how much better they feel. They are more alert and able to work and care for their families.
  • Job satisfaction with the nurses and care coordinators has increased.
  • Care coordinator positions will pay for themselves by process management and billing Medicare wellness exams.
Date Last Reviewed:  November 2019

More Information

Health center's Uniform Data System (UDS) data
For more information about this promising practice, contact:
Lisa Bricker, RN, MS, Executive Director
Erin Frazier, RN, BSN, Director of Operations