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Provider Success Story – Luis E. Guerrero MD: Connecting Patients with Local Resources

Between 1993 and 2011, the percentage of adults with diabetes in New York City has more than doubled. In 2011 650,000 adult New Yorkers reported having diabetes and an estimated 230,000 additional New Yorkers were unware that they were living with diabetes.2 In New York City, three of the neighborhoods with the highest prevalence of diabetes are located in the Bronx: Fordham-Bronx Park (14.6%), Northeast Bronx (13.9%), and the South Bronx (13.9%).

Dr. Luis Guerrero, a private independent primary care practitioner, has been practicing in the Soundview area of the South Bronx for over 25 years. Being located in a neighborhood with one of the highest prevalence of diabetes, Dr. Guerrero sees a high volume of patients who have prediabetes and can potentially develop type 2 diabetes. “The Bronx has a high population of [people at risk for diabetes],”emphasized Dr. Guerrero. Because of this, Dr. Guerrero decided to take a proactive approach and look for ways to engage with his patients who have prediabetes in an effort to reduce their chances of developing type 2 diabetes.

Dr. Guerrero soon realized that engaging with his patients who have prediabetes would be more challenging than he initially thought. One of his main challenges was educating his patients about the importance of lifestyle changes, such as physical activity and a sustainable diet. Without weight loss and moderate physical activity, 15 to 30% of patients with prediabetes could develop type 2 diabetes within five years.

By collaborating with NYC REACH’s Clinical-Community Program Linkages team, Dr. Guerrero was able to learn about evidence-based intervention (EBI) programs available for his patients. One EBI program that has helped Dr. Guerrero and his patients is the National Diabetes Prevention Program (NDPP). The NDPP is a lifestyle change program designed to help participants lose 7% of their body weight to prevent or delay the onset of type 2 diabetes. Participants of the NDPP have been proven to reduce their risk of developing type 2 diabetes by 58%. Moreover, this reduction in risk rises to 71% in participants over 60.

“QTAC has been very helpful. Before we were making referrals through hand-written fax, and sometimes they were never received. But now, it’s so much easier.”

Dr. Guerrero was one of the first NYC REACH providers to start referring his patients to the NDPP. Initially, clinical providers referred their eligible patients to the NDPP using a paper referral system. Through this method, referrals would be hand-written and faxed over to the location that offered the workshop.

Because this paper-based method presented some challenges with program coordination, a streamlined process was needed. The CCPL team contracted with the Quality & Technical Assistance Center of New York (QTAC-NY), a national online registration and data management portal, to develop a new online tool that allows providers in clinical settings to search and register for NDPP classes being offered within their community by a diverse set of organizations, which became the QTAC-Compass Portal.

The QTAC Physician Portal offers providers and healthcare staff the ability to choose from workshops based on location, time of day and language. QTAC also provides feedback to providers regarding their patients’ attendance in the NDPP workshop, weight loss, and physical activity. “QTAC has been very helpful,” said Tania, a nurse working at Dr. Guerrero’s practice. “Before we were making referrals through hand-written fax, and sometimes they were never received.

But now, it’s so much easier.” Vanessa Cordero, a staff member at Dr. Guerrero’s practice, emphasizes the importance of these progress reports. “Once Dr. Guerrero receives the progress report, he’ll refer to it and speak to his patients about it when they come in to see him.”

Dr. Guerrero is one of many NYC REACH member providers utilizing the QTAC-Physician Portal to refer his patients to evidence-based intervention programs in the community. Since the implementation of QTAC, there has been an increase in the number of referrals. Between January and December of 2016, providers all over New York City have referred over 3,000 patients to an EBI program.

For questions or additional information on how QTAC can be utilized in a practice, please contact EBI_Referrals@health.nyc.gov.