Be Well Lake County

Community Cooperation for Medically Underserved Diabetes Patients

More than seven percent of Lake County’s 700,000 residents are battling diabetes. Each year, hundreds of diabetes patients in Lake County are hospitalized due to complications with their disease.  NorthShore University HealthSystem and the Lake County Health Department and Community Health Center recognized that many of these complications can – and should – be prevented.  The two joined forces to develop what has grown to a fully comprehensive diabetes management program for more than 1,000 medically underserved patients.

Health Care Challenge:
Proper diabetes management is critical, since complications can lead to heart disease, stroke, blindness and kidney disease.   NorthShore University HealthSystem and the Lake County Health Department and Community Health Center have collaborated to develop “Be Well-Lake County.”  This program for medically underserved diabetes patients provides disease management, subspecialty care, assistance with medication and testing supplies, on-site Hemoglobin A1C testing, an exercise training component and a community garden. Be Well provides integrated diabetes treatment, education, and support resources to more than 1,000 medically underserved patients.

Be Well patient Petra Narvaez was introduced to the program when she was hospitalized for one week because her blood sugar levels were too high.  It was at that point that she learned her cataracts was related to complications with her diabetes.  “I couldn’t believe it – I felt overwhelmed, especially with the amounts of medication I had to start taking,” recalls the 64-year-old North Chicago resident.  “I didn’t know if I was going to be able to see again.”

Family Medicine’s Solution:
Be Well-Lake County has grown to become a comprehensive, fully integrated program.  Since its inception, Be Well has always been patient focused.  But the physicians who are part of this program think beyond their “normal” focus.  For example, staff recognized that patients’ access to fresh, healthier food options were limited due to the food desert in which they were living.  Physicians, program staff and NorthShore donors worked together to start a now fully-functioning community garden.   Patients maintain and water the garden throughout the summer months, and each year patients harvest hundreds of pounds of produce to enjoy with their families.

In another example of community cooperation, Be Well physicians noticed that patients were facing major gum disease and oral health issues due to complications with their diabetes.  Be Well launched a dental program that continues to see patients – some of whom have not visited a dentist in 10+ years.

The lines of responsibility in this partnership are clear.  The Health Department provides the primary care physicians, medical assistants, nurses, nurse practitioners, a dietitian, a program coordinator, a case manager and a translator. NorthShore University HealthSystem provides subspecialty care, marketing and public relations support, a grant writer and fundraising assistance.

This nationally recognized program offers a coordinated network of services, including:
-    Assistance with medication and testing supplies
-    Subspecialty care access for cardiology, ophthalmology, endocrinology, podiatry, and nephrology
-    On-site Hemoglobin A1C testing
-    Diabetes self-management education classes and support group
-    Fitness program
-    Paid membership to a fitness center for those who qualify
-    Nutrition education offered by a registered dietitian

Patient Benefits:
Be Well staff worked with Petra to better manage her blood sugar levels.  She met with the Be Well dietitian for medical nutrition therapy.  She lost weight and was finally given a second chance to see again.  Petra underwent eye surgery at NorthShore with a Be Well ophthalmologist, and she regained her eyesight.   “It has changed my life for the best.  It was extremely difficult for me to accept the fact that I had lost my eyesight due to cataracts and other complications.  I received the care I needed and for this I am most grateful.”

Petra regularly keeps her doctor appointments.  She takes full advantage of additional support offered through the Be Well program, such as meeting with her dietitian to improve her eating and dietary choices, and continuing her retinal screenings to monitor her vision.  Petra has attended healthy cooking demonstrations, where she learns how to cook with healthier options to better manage her diabetes.  She has also found a support system and respite among fellow patients and physicians of the Be Well-Lake County diabetes management program.  Many Be Well patients find that simply knowing they are not alone in their struggle with diabetes provides inspiration and support.

Petra’s life-changing experiences have – quite literally – impacted her outlook and approach to her health.  Her advice to other patients is clear:  “For people struggling with diabetes out there - seek treatment right away.  And follow the doctor’s advice and recommendations!” she advises.  

Contributed by NorthShore University HealthSystem