How St. Anthony’s Medical Clinic is Enhancing Diabetes Care: Rosa’s Journey to Reconnection

January 30, 2025

At St. Anthony Foundation, we are committed to continually improving our services to meet the needs of our community. One of our recent initiatives focused on improving the rate of HBA1C testing for patients with poorly controlled diabetes (A1C ≥ 9). This project was essential, as regular A1C testing every three months helps prevent severe complications like kidney failure, cardiovascular disease, and blindness, and significantly improves patients’ quality of life.

For Rosa, diabetes had become something she tried to ignore. After losing her insurance and missing multiple appointments, she felt disconnected from care. She knew her diabetes was out of control, but the fear of bad news kept her from seeking help. She avoided checkups, not realizing that delaying care was putting her at a higher risk for blindness, amputation, or kidney failure.

The Problem and the Goal

Diabetes affects over 38 million people in the U.S., making it the 8th leading cause of death. At the St. Anthony’s Medical Clinic (SAMC), 21% of diabetic patients, like Rosa, had an A1C level of 9 or higher. However, only 61% of these patients were tested within the recommended three-month period. To address this gap, our team set a SMART goal: increase testing rates to 84% by May 10, 2024.

Rosa’s case highlighted the need for a more proactive approach. She had fallen through the cracks, with no follow-ups and no safety net. That changed when our Diabetes Management (DM) team reached out to her through our A3 Project, which focused on identifying and reconnecting patients who were out of care.

Approach and Interventions

Through the A3 Project, we identified key barriers preventing patients from receiving routine A1C testing. Our team implemented several solutions, including:

Outreach to disconnected patients – Rosa received a personal call from our care team, inviting her back to the clinic without judgment or pressure.
Re-enrollment support – Our team helped Rosa navigate the process of reinstating her insurance, ensuring she had access to care.
Team-based approach – Once Rosa returned, she was supported by our DM team, which helped her get back on track with her diabetes management.

This intervention was critical for Rosa. Had she continued to avoid care, she might not have received urgent medical attention when she needed it most. Months after reconnecting, she required an emergency procedure and had to have a pacemaker placed. Thankfully, she was already under medical supervision, which allowed for a timely intervention that likely saved her life.

Results

The impact of our outreach was profound. Not only did we surpass our original goal, achieving an 86% testing rate—above the national average—but we also saw a decrease in the number of patients with uncontrolled diabetes. Rosa’s story exemplifies the difference this initiative has made. She went from being disconnected and at high risk to receiving life-saving care, all because of the systems we put in place.

Our improved workflow remains in effect today, continuing to make a difference for diabetic patients across our community.

A Testament to Our Mission

Rosa’s journey reflects St. Anthony’s commitment to whole-person care and ensuring that no one falls through the cracks. Your support enables us to reach patients like Rosa, helping them regain control of their health and, in some cases, saving lives.

Thank you for standing with us in making a difference!

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