An estimated 1 million New Yorkers have diabetes, with 19 percent undiagnosed. Uncontrolled diabetes can have serious consequences, such as blindness, chronic kidney disease, and lower extremity amputations.

To combat this epidemic, association member NYC Health + Hospitals, in New York, in July launched a new primary care–centered diabetes management program.

“There isn’t a single silver bullet for treating diabetes,” says Dave Chokshi, MD, the health system’s vice president and chief population health officer. “With this multipronged approach, we can help many patients who are struggling to manage their diabetes and streamline their care by tracking their blood sugar levels and food intake, customizing their medication, and being more proactive around preventative screenings.”

That multipronged approach starts by integrating specialty care into routine primary care. The health system will incorporate 20 clinical pharmacists into primary care teams to aid in medication management. Since uncontrolled diabetes can contribute to diabetic retinopathy, which can be asymptomatic and cause blindness, regular preventative screenings are important. NYC Health + Hospitals plans to increase access to advanced teleretinal screenings by integrating them into routine primary care visits, instead of referring patients to an ophthalmologist.

The health system also will provide remote patient support through a peer mentorship program that matches patients with mentors who successfully live with diabetes. Through regular phone calls, mentors help patients navigate social risk factors and barriers to care, with the goal of improving HbA1c levels and quality of life. This program, a collaboration with social therapeutics company InquisitHealth, currently is offered at NYC Health + Hospitals/Kings County and NYC Health + Hospitals/Gotham Health, Cumberland, and participants speak highly of the opportunity.

“Knowing that my mentor has successfully managed her diabetes and understands my lifestyle and culture makes me feel confident that the advice shared will be easy to apply to my everyday life,” says Helen Augustus, a mentoring program participant.

The health system also harnesses BlueStar, an app that provides individualized coaching, reminders and support, and educational tools. Patients at NYC Health + Hospitals/Metropolitan and NYC Health + Hospitals/Queens can connect to their pharmacies’ medication tracking, blood glucose meters, labs, and activity trackers to receive real-time feedback between clinic visits.

NYC Health + Hospitals hopes this program will increase access to diabetes care and improve population health for the communities the hospital serves. To learn more about how essential hospitals are improving population health, visit