Ohio University

 Focus Areas

Using the Model for Improvement as our quality improvement framework, the Southeastern Ohio Regional Quality Improvement Hub helps participating organizations identify care gaps, test practical solutions, and use data to determine whether changes lead to improvement.

Through iterative Plan-Do-Study-Act (PDSA) cycles, participating sites have tested and adapted strategies based on their patient populations, staffing, workflows, and available community resources. This work includes:

• Expanding access to continuous glucose monitoring: Supporting sites in identifying eligible patients, improving prescribing workflows, conducting targeted patient outreach, addressing insurance and access barriers, and helping patients understand and use CGM data.
• Improving access to diabetes education: Connecting patients with in-person, virtual, and community-based diabetes self-management education and support services, while testing new referral, outreach, and follow-up approaches.
• Strengthening preventive diabetes care: Improving completion and documentation of important services such as diabetic eye exams, foot exams, kidney health monitoring, and timely follow-up for patients with elevated A1c levels.
• Optimizing medications and clinical care: Integrating clinical pharmacists and other members of the care team to review medications, support treatment adjustments, interpret CGM data, and provide individualized education for patients with complex needs or persistently elevated A1c levels.
• Screening for social needs: Testing electronic, verbal, and paper-based screening approaches to identify needs related to food, transportation, housing, medication affordability, and other factors that affect health.
• Creating connections to community resources: Strengthening referral pathways to diabetes navigators, community health workers, food assistance programs, nonprofit pharmacies, and other local services, with an emphasis on closing the loop so practices know whether patients successfully received support.
• Addressing food insecurity: Developing on-site food pantries, food prescription programs, and partnerships with local food organizations to improve access to nutritious foods that align with patients’ health needs and preferences.
• Building a culture of continuous improvement: Providing quality improvement coaching, shared learning opportunities, data review, workflow mapping, and peer exchange so participating organizations can test changes, learn from results, and sustain successful practices.