The Diabetes Medical Home Extender Program

DiabetesThe Diabetes Medical Home Extender Program is a LifeBridge Health M. Peter Moser Community Initiative pilot project designed to educate and empower high risk diabetics whose poor health status is influenced by the poverty. Internal medicine physicians coordinate primary care and supportive services in collaboration with a community nurse and a social worker to help these patients better manage their conditions.  Through outreach and by developing supportive relationships, community health workers provide education and guidance in health topics and offer specific tips for healthy behaviors. This educational focus is supported by referrals to other resources that can provide a critical link between the health care and human services systems and the project participants, their families and communities.