Leveraging umbrella licenses to increase access to diabetes self-management programs in high-need NYC neighborhoods

The Issue

In New York City, diabetes is a key contributor to illness and disability and the 5^th leading cause of death. Diabetes risk and burden are overwhelmingly concentrated in the Bronx, Brooklyn, and Queens.

• In 2022, 643,000 adults were living with diabetes in the Bronx, Brooklyn, and Queens, accounting for 81% of all adults with diabetes in NYC.
• Many adults with diabetes do not meet blood glucose management goals, with 16.5% in the Bronx and 14.4% in Brooklyn having very high blood glucose levels (A1c values greater than 9%), increasing their risk of blindness, kidney disease, and other complications from diabetes.
• The rate of diabetes-related lower extremity amputations in the Bronx (74.5 per 100,000) is double the rate in Manhattan (36.3 per 100,000).

Despite this context, many New Yorkers in the Bronx, Brooklyn, and Queens have limited access to diabetes self-management education and diabetes support programs.

Our Approach

To address this issue, with funding support from the Centers for Disease Control and Prevention (CDC), NYC REACH leveraged two umbrella licenses to expand access to high-quality diabetes programs.

1. The Association of Diabetes Care & Education Specialists (ADCES) DSMES Accreditation: Through our ADCES umbrella license, we partnered with health systems, including Montefiore Care Management, to help them become accredited Diabetes Self-Management Education and Support (DSMES) programs. By providing tailored monthly technical assistance, NYC REACH supported 3 health systems in electronic health record (EHR) documentation development, workflow redesign, and alignment with the National Standards for DSMES. NYC REACH also supports partners in developing the infrastructure needed for Medicaid and Medicare billing, including determining eligibility, ensuring necessary EHR documentation, and supporting accurate provider referrals. This hands-on support ensures partners meet and sustain all accreditation requirements as they provide reimbursable, high quality, patient-centered diabetes care and education services.
2. Self-Management Resource Center (SMRC) License: Through our SMRC umbrella license, NYC REACH engaged and provided training to 12 community-based organizations and two NYC Health Department Neighborhood Health Action Centers to deliver a total of 29 Diabetes Self-Management Program (DSMP) workshops for priority populations in the three boroughs. NYC REACH provided DSMP delivery organizations with capacity building and skill development training, individualized technical assistance, clinical-community partnerships to support recruitment, partner networking opportunities, data management and quality improvement tools, and free access to the Unite Us referral platform to address health-related social needs.

Our Impact

From July 2023 to December 2025, NYC REACH and its partners (3 hospitals, 12 community-based organizations, and two NYC Health Department Bureaus of Neighborhood Health) have:

• Enrolled over 2,300 participants in diabetes self-management programs, of which over 95% were New Yorkers identifying as Black, Latino, 65 years or older, or living in neighborhoods experiencing high or very high poverty.
• Reduced the proportion of DSMES participants with A1C >9% from 52.8% at baseline to 28.7% 2-6 months after the program. (Calculated from 216 participants with complete A1C results)
• Reduced the proportion of DSMES participants reporting high diabetes-related distress from 14.2% at the beginning of the program to 7.6% at the end. (Calculated from 528 participants with complete diabetes distress scores)
• Improved DSMP participants’ self-efficacy to manage their diabetes, indicated by a mean diabetes self-efficacy score of 6.36 out of 10 at the beginning of the program increasing to 8.58 at the end. (Calculated from 206 participants with complete diabetes self-efficacy scores)
• Enabled most DSMP participants (88%) to complete the program, and nearly all expressed high satisfaction.

Next Steps

The next phase of our work will focus on recruiting additional organizations interested in DSMES accreditation or our SMRC umbrella license, ongoing training and technical assistance to support new and existing partners, and utilizing Unite Us to address participants’ health-related social needs that influence recruitment and retention in diabetes programming.

Funding Source

CDC DP23-0020: Advancing Care and Equity for Diabetes Prevention and Management (ACED). Learn more about our ACED program.

References

Li W, Seil K, Paudel P, Castro A, Sun Y, Gurung S, Robles-Torres L, and Van Wye G. Summary of Vital Statistics, 2023. New York, NY: Bureau of Vital Statistics, New York City Department of Health and Mental Hygiene.

Olson D, Zhilkova A, Jiang Q, et al. Diabetes and Health Inequities among New York City Adults. New York City Department of Health and Mental Hygiene: Epi Data Brief (146); May 2025.