In a city where chronic conditions like diabetes disproportionately affect underserved communities, one local health center is rewriting the script on patient care.
The Joseph P. Addabbo Family Health Center (JPAFHC) in Southeast Queens is making significant strides in diabetes care in New York City with its Diabetes Management Initiative, a program designed to improve health outcomes for high-risk patients.
Since its launch 18 months ago, the initiative has successfully helped over 500 patients lower their A1C levels and take control of their diabetes. Through the use of cutting-edge technology, such as the Dexcom G7 Continuous Glucose Monitoring System (CGM) and FreeStyle Libre GCM, combined with comprehensive patient education, the program is empowering individuals to manage their health better and significantly reduce their risk of serious complications.
The Diabetes Management Initiative uses real-time blood sugar tracking through the Dexcom G7 CGM, allowing patients to monitor their glucose levels throughout the day and make informed decisions about their diet, medication, and lifestyle.
”The Dexcom is a continuous glucose monitor that we put on the patient’s arms that allows us to share with them information about their glucose levels,” explained Dr. Kecia Ford, MD, Internal Medicine. It benefits the patients quite a lot because it empowers them. They get to see how food, medication, and exercise affect their glucose levels.”
“ When they initially join us at the clinic, we are having them come quite a lot because it gives us an opportunity to make adjustments early on,” Dr. Ford said. Appointments are customized to the patient’s needs when starting the program, depending on the level of their A1C and the patient’s control over it.
This constant monitoring and personalized education about chronic disease management provides patients with the tools they need to manage their condition. The program has been praised for its ability to transform diabetes care by offering accessible, high-quality healthcare solutions to underserved communities in New York City.
Dr. Ford noted that seeing tangible results from the glucose monitoring allows patients to stay motivated.“ When we do their lab work, or they come, and we print out their tracings, they see in real-time the drawings of their glucose levels. They can see the progress from really high to down within the normal range,” she said.
“Our mission is to bring innovative, high-quality healthcare to underserved communities,” said Dr. Ari Benjamin, Chief Medical Officer at JPAFHC. “This program is a game-changer in chronic disease management, proving that access to the right tools and education can lead to life-changing results.”
The Diabetes Management Initiative is explicitly tailored to high-risk patients, especially those with an HbA1c level of 8.5 or greater. Individuals with diabetes face a significantly higher risk of developing cardiovascular diseases such as heart attacks and strokes, particularly when compounded by conditions like hypertension and high cholesterol.
By targeting these high-risk individuals and helping them manage their blood sugar levels effectively, the program mitigates cardiovascular risks and improves patients’ overall health and quality of life.
Dr. Ford highlighted the importance of this comprehensive approach to diabetes care.
“People with diabetes are twice as likely to experience heart attacks, strokes, and heart failure compared to those without the condition. Through our High-Risk Diabetes Clinic, we use education and technology to empower patients and help them control their diabetes, heart health, and overall well-being,” she said.
Nearly 300 patients have graduated from the program so far, signifying that patients have lowered their A1C levels substantially to be at a manageable level. ”We actually did quite a good job getting those folks under control, and now…they come to us, they still come, but they don’t come as frequently because once you get under control, your visits are every three months,” Dr. Ford explained.
Terrance Pitt, a patient enrolled in the program, shared his personal journey. “Transforming my habits has been challenging, but this program made the journey rewarding. I used to feel exhausted all the time, but now, I feel energized, sleep better, and live a healthier life. This program has truly given me a second chance to thrive,” he noted.
The Diabetes Management Initiative also underscores the importance of regular medical follow-ups to monitor progress and adjust treatment as needed.
“Consistent blood sugar control is crucial in preventing complications like nerve, kidney, and eye damage,” explained Dr. Ifeanyi Oguagha, MD, Internal Medicine.“Regular follow-ups with our team allow us to make adjustments in treatment and intervene early, ensuring better health outcomes for our patients.”
The initiative’s success has shown that integrating innovative technologies like continuous glucose monitoring with patient education can significantly improve chronic disease management and health outcomes.
As one of New York City’s leading Federally Qualified Health Centers (FQHCs), the Joseph P. Addabbo Family Health Center (JPAFHC) provides comprehensive medical, dental, behavioral health, and social support services to underserved communities in Southeast Queens—including Rockaway and Jamaica—as well as Red Hook, Brooklyn.
