The patients cared for at the Center for Diabetes and Hypertension at the Saint Peter’s Family Health Center in New Brunswick number in the hundreds.  Many are unemployed and have no health insurance, some are working but are underinsured; others are immigrants who have recently arrived in the area while others are longtime residents. Some did not know they suffered from diabetes and hypertension. All have been unable to manage two of the most chronic diseases affecting adults today because they do not have a family doctor they see regularly. Because of a new model of care practiced at the Family Health Center – the patient-centered medical home – they are now better managing their health.

The patient-centered medical home serves adults 18 years of age and older and non- pregnant women who have diabetes and hypertension and have no insurance or are underinsured. The short term goal of the             program is to identify patients with both conditions and provide them with the care and resources they need in one convenient location. The long term goal is to reduce hospital admissions and emergency room visits. 

“It is largely known that diabetes has reached epidemic proportions. In particular groups, and also in communities where people do not have access to care, a program like this is important because you are able to provide the fundamentals of care to patients who need it,” says Anne Marie Van Hoven, MD, an     endocrinologist at the Center. These fundamentals of care focus on the patient’s medical and social needs. In addition to primary care and follow-up care, the staff provides education on managing medications; living and coping with chronic disease; nutrition counseling; foot, skin and eye care; and information about community resources. 

 “The beauty of this program is that it provides education about the disease and the nutritional management of the disease which is the foundation of diabetes management,” adds Dr. Van Hoven. “As a physician, I prescribe 10 to 15 medications to everyone, but the patients who do the best are the ones who make lifestyle changes. It’s hardly about the medications. It’s the life-style changes that make the difference.” 
Nutritionist Catherine Van Doren, RD, CDE, and Yolanda Jorge, APN, are charged with providing education and support. After patients    meet with a primary care physician at the Center, appointments are scheduled for a nutritional consultation and a separate session where patients are taught about diabetes and what patients can do to manage the disease on their own. These visits last an hour. It’s at this stage that barriers are identified to successful self-management and treatment. Patients are invited to attend the Spanish-                             language support group or the English-language group that meets once a month at the How Lane Center. The nutritionist sets the agenda based on the patients’ needs and topics range from managing stress to basic everyday concerns such as food shopping and cooking healthy foods.  “It is important not to rush and to work at a good pace so the patient does not become overwhelmed,” says Jorge. “If the patient is not comfortable, they cannot trust you; and if they don’t trust you, they don’t come back.” Why diabetes and hypertension? 
According to research, underserved populations are more at risk for developing diabetes and hypertension as a complication of five factors:

  • An increase in obesity 
  • Lack of compliance with medication
  • Financial concerns
  • Lack of understanding of disease processes
  • Lack of understanding about the relationship between lifestyle and developing diabetes with hypertension. 
The Center’s patient stories prove this to be true. A female patient who until now has not managed her diabetes and hypertension is part of the growing numbers in recent years of long term, unemployed living in New Jersey and throughout the country. When she was referred to the Center for treatment, her A1C test result was 14. Today it has been reduced by more than 50 percent to 6.1. The A1C test is used to diagnose diabetes as well as reveal how well patients are managing their diabetes. The test results reflect a patient’s average blood glucose over a three-month period. Specifically, the A1C test measures what percentage of hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated).

A male patient who weighed close to  400  pounds and whose kidneys were not functioning well is now on the road to better health because he has changed his diet  dramatically and is taking insulin, one of the medicines used to treat diabetes. Insulin is a hormone produced by the cells in the pancreas that helps to regulate glucose levels in the body. Patients with diabetes do not produce enough insulin.

The establishment of a medical home for the treatment of diabetes and hypertension in underserved populations is tied to the Saint Peter’s mission of caring for all. “It aligns beautifully because we are helping people who need our help the most,” says Dr. Van Hoven. “What I love most about this program is that it treats the whole person which is the goal of all treatment. There is nothing about diabetes education that doesn’t help everything, that doesn’t improve overall health. We are helping patients to become healthy.” 

For more information, call our Patient- Centered Medical Home at Saint Peter’s Family Health Center, 732-339-7672


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