Improving Diabetes Care and Outcomes on the South Side of Chicago

Cooking demonstrationImproving Diabetes Care and Outcomes on the South Side of Chicago is a seven-year project funded by the Merck Foundation, through the Alliance to Reduce Disparities in Diabetes, and the National Institute of Health. Spearheaded by Drs. Monica Peek and Marshall Chin of the University of Chicago, the project engages patients, providers, clinics, and community collaborators to improve health care and outcomes on the South Side of Chicago, a predominantly working class African-American community.

The project is multi-faceted and involves four main components:

  1. Patient education and empowerment
    We educate and empower patients to manage their diabetes and communicate effectively with their doctors. Preliminary results indicate that these classes have significantly improved patients’ HbA1c levels, diabetes self-efficacy and diabetes self-management behaviors.
  2. Provider workshops
    We work with health care providers to troubleshoot the challenges of communicating with their patients, recognize cultural stereotypes on which they may unknowingly rely, and effectively motivate patients towards health behavior change.
  3. Clinic system redesign
    Our team facilitates quality improvement (QI) programs redesigning clinic operations to improve care for diabetes patients. QI initiatives have included instituting group visits, patient medication cards, peer support groups, flow sheets, nurse case management, and patient registries. New initiatives include improving access and tracking of specialists visits, employing community health workers/patient navigators, coordinating care, and implementing other team-based care initiatives.
  4. Community collaborations
    We collaborate with existing community resources to create sustainable collaborations that support diabetes patients outside of the health care system. We collaborate with food pantries, the Chicago Park District, prescription discount cards, farmers markets, media channels, grocery stores and other organizations.

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We work with six clinics on the South Side of Chicago and are implementing each of the above four components in each clinic.

Principal Investigators: Monica Peek, MD, MPH; Marshall H. Chin, MD, MPH
Research Team: Robert Nocon, MHS; Nyahne Bergeron, MPH; Kathryn Gunter, MPH, MSW; Yolanda O’Neal, MPA


2013 South Side Diabetes Study Team

Funding Sources:
“Improving Diabetes Care and Outcomes on the South Side of Chicago” is part of the Alliance to Reduce Disparities in Diabetes, a five year initiative supported by The Merck Foundation, the philanthropic arm of Merck & Co. Through grants to five organizations in the Alliance and a National Program Office, the Merck Foundation supports comprehensive, multi-faceted, community-based programs that address the key factors to improve health outcomes for people living with diabetes.

This research is also supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) through an R18 (DK083946-01A1), the Chicago Center for Diabetes Translation Research (P30 DK20595), and the Diabetes Research and Training Center (DRTC) (P60 DK20595).

Pilot work for this project was funded by a University of Chicago Clinical and Translation Science Award (CTSA).


Learn more about the South Side Diabetes project at their website


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