WIN for Diabetes

Ambulatory Care Network Community Programs

Residents of low income New York City neighborhoods are twice as likely to have diabetes, 2.8 times as likely to be hospitalized for complications associated with diabetes, and 2.3 times as likely to die from complications associated with diabetes. In 2004, the NYC Department of Health and Mental Hygiene estimated that there are 19,000 residents with diabetes in the Washington Heights-Inwood community. Thirty-five percent of these residents had limb amputations and 24% had at least one diabetes-related hospitalization. Hospitalizations are likely underestimated, as diabetes often is not the admitting diagnosis for these patients.

To address these local disparities, in January 2012, NYP and community partners developed and implemented the WIN for Diabetes program based upon the successful WIN for Asthma program. This program serves patients of the ACN with poorly managed diabetes and their caregivers through community based, motivational self-management support, home visits, comprehensive diabetes information, and links to clinical and social services. Currently, more than 100 patients are actively enrolled in the year-long WIN for Diabetes care coordination program.