Southcentral Foundation Uses Data and Community Health Aides to Manage Diabetes

Southcentral Foundation Health CenterSouthcentral Foundation (SCF) HRSA BPHC Exit Disclaimer is an Alaska Native-owned, nonprofit health care organization serving Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Borough, and 55 rural villages in the Anchorage Service Unit HRSA BPHC Exit Disclaimer. SCF operates the Nuka System of Care, a customer-driven, relationship-based health care system, where SCF patients are referred to as customer-owners.

SCF’s Diabetes Management Program has a two-pronged approach, using data and Community Health Aides:

Using Data

SCF has created a diabetes registry and action list that captures the preventive, screening, and disease/condition status of each provider’s panel.  It includes information on customer-owners’ risk factors, co-morbid conditions, guideline-based elements of care, including test results, and data on UDS measures. UDS data are reviewed monthly and other clinical data are reviewed weekly. These action lists, which are available on the SCF intranet, are designed to provide clinical teams with the evidence-based information they need to care for their customer-owners. Data drives quick action so if a customer-owner is identified as being due for a test or exam, SCF reaches out to him/her and makes a quick intervention.

Community Health Aides Program (CHAP)

SCF has a unique challenge with providing care to its population—the majority of the villages it serves are accessible only by plane or snowmobile, depending on the season. This makes caring for customer-owners with chronic conditions, such as diabetes, difficult.

The Community Health Aide Program (CHAP) HRSA BPHC Exit Disclaimer is unique to Alaska and is an integral health care provider group in rural areas. Community Health Aides (CHAs) are high school graduates who have received training to provide remote care by protocol, including diabetes management.  Living and working in remote Alaskan communities, they are supported by distant site SCF physicians through telehealth. They follow up on the diabetes action lists with customer-owners in these locations, connect customer-owners to specialty services using telehealth and help coordinate health educator visits to these remote sites. They also encourage customer-owners to use the My Alaska Wellness app to communicate with providers, view their medical record and access diabetes lifestyle management resources.

How to Implement

While CHAP is a Tribal organization, health centers serving other populations in remote settings can replicate elements of the CHAP model. Some of the replicable parts of SCP’s diabetes management program are:

  • Updating clinical data from the EHR daily into SCF’s database. Having a department focused on data drives systematic improvement. System-wide data that drills down to the individual level make it possible for SCF to manage the sites over its remote service area.
  • Creating action lists in the EHR, to get a snapshot of a patient’s overall health and a checklist of actions to take to help the patient with diabetes management.
  • Reviewing data on a weekly and monthly basis to identify patients who need follow up
  • Having at least one on-site staff member in remote clinic sites who is trained to assess and refer patients
  • Using telehealth to connect to specialists and health center primary care providers
  • Encouraging patients to use technology, such as apps and patient portals, to communicate with practitioners and find resources
  • Bringing health educators to remote sites on a regular basis
Date Last Reviewed:  November 2018

More Information

Health center's Uniform Data System (UDS) data

View a sample diabetes action list (PDF - 64 KB)

For more information about this promising practice, contact:

Brianne Gorham, M.A.
Manager of HRSA Grant