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In 2002, with support from The Commonwealth Fund, the National Public Health and Hospital Institute (NPHHI) created a consortium of safety net hospital systems to work together to address common concerns regarding the care of patients with diabetes. As part of that project, NPHHI conducted a survey of patients with diabetes who received at least some of their care from four Consortium hospital systems: Cambridge Health Alliance; Community Health Network of San Francisco/San Francisco General Hospital; Cook County Bureau of Health Services; and LSU/Medical Center of Louisiana at New Orleans. Patients were surveyed on multiple domains of care, including overall satisfaction, access to important diabetes-related services, self-management, health status, and communication with their health care providers.

This effort, known as the Consortium for Quality Improvement in Safety Net Hospitals and Health Systems, was the first initiative of its kind to bring a group of safety net hospital systems together to examine quality of care provided for diabetes patients. The work of the Consortium underscores the critical role that safety net hospital systems play in delivering high quality diabetes care to a patient population that is primarily low income, ethnically and racially diverse, and that has high rates of literacy problems. The study signals the need for comprehensive programs to support the care of vulnerable patients with chronic conditions and highlights areas for improved communication between providers and patients. Project outcomes can be summarized around several major findings:

  • Although Consortium members care for large numbers of patients with diabetes who are?racially and ethnically diverse, low income or uninsured, and often with limited English?or literacy proficiency, the study found few significant differences among racial groups?regarding assessment of health status and access to care.
  • Despite programs at safety net hospitals to increase access to care for patients, uninsured patients continue to report poorer control of their diabetes and disparities in access to care. Compared with patients with any insurance coverage, fewer uninsured patients reported having a primary care provider and more reported skipping medications due to cost
  • Up to one-third of the patients at Consortium hospital systems reported having languages other than English as their primary language, and one-quarter reported having health literacy problems. Patients commonly reported problems understanding basic instructions involved in diabetes management. Safety net hospital systems are continually challenged to provide culturally and linguistically appropriate services for their diverse populations. Appropriate provider-patient communication becomes a particularly salient issue for patients with chronic illnesses like diabetes that require self-management and understanding of providers' instructions. More research is necessary to understand the cultural and linguistic needs of various patient populations and to design targeted programs that address these needs in the context of comprehensive care management.
  • The NPHHI study revealed the importance of providing comprehensive care that draws on relevant health professionals in the management of chronic illness. Diabetes teams should be expanded to include health care professionals and social workers able to address the variety of factors that affect diabetes care for low-income and minority patients. Much more work is necessary to develop comprehensive, tailored diabetes management programs that take into account literacy, language, and co-morbidities.
  • The study identified several key areas for improvement in care for patients with diabetes in safety net hospitals, specifically around patient-provider communication. In general, survey respondents reported few problems with the care they received and their communication with providers, but not consistently across race and ethnicity. A sizable group of patients (one-quarter or more) reported having difficulty understanding their providers' use of medical terminology, identified a need for improved communication, or noted the providers' failure to take into account the patient's religion or culture.
  • Although patients generally identified few problems with the care they received, a remarkably high proportion of survey respondents indicated they were in fair or poor health and/or had pain that interfered with their ability to exercise. In part, this is a reflection of the experiences of patient populations in safety net hospital systems, who tend to suffer from co-morbidities such as heart disease and depression.


Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.

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