Program Description:

The purpose of Salud A Su Alcance Diabetes Management Program (SASA-
DMP) is to improve the prognosis of high risk and non-compliant diabetic patients identified by participating providers. Eligible patients are those who meet the referral criteria defined by SASA-DMP. Each patient once enrolled is assigned a team of healthcare workers, comprised of his/her primary care provider (PCP), case manager, a program coordinator, a community health outreach worker and an administrative staff.
Patients receive six months of intensive case management in their homes, aimed at care coordination, health education and self-management skills. A review of the literature suggests that this approach to care has proven to be highly effective in increasing quality and cost effective care.

The responsibility of the Community Health Outreach Workers and Case Managers is to help patient adhere to the treatment plan you prescribed and facilitate access to services not available in your practice, including pharmaceuticals, specialty and social services, diabetic education, or peer support. Patients' ongoing progress is continuously fed to their PCPs, which allows for treatment modification/adjustment as needed. Results are monitored, changes in behavior are observed as patients' progress towards meeting their pre-established goals. At the end of this period, the patient's care is transitioned from intense monitoring twice per week to twice per month. This phase of the program is intended to support patients in their adherence to treatment plan.

Our Medical Directors Committee has selected three clinical indicators to measure success of these interventions, they include: LDL, Hemoglobin A1c. As such it is essential that you provide us with the information when it becomes available.

It is well documented that diabetes is truly a life-altering disease that affects all aspects of the patient's life. We believe that a strong network of social support will foster compliance, reduce stress, minimize associated diseases and significantly improve patients overall quality of care.

We are excited about the opportunity to work with you. We can schedule a one- hour presentation for you and your staff to go over the program in more detail. Please feel free to contact us at 212-342-1618 for additional information.

Carlene Duncan
Program Coordinator

Denise Abel
Case Manager



PDF Version

Diabetic Management CheckList

Referral Form