SUN-660 - Driving Progress in Diabetes Care: Structured Panel Management for Improved Glycemic Outcomes in A Primary Care Practice

Background
Adults with diabetes and hemoglobin A1c (HbA1c) levels greater than 9% are at increased risk for complications and often reflect gaps in care coordination, follow-up, and treatment intensification. Primary care practices face persistent challenges in managing complex chronic disease at scale, including care fragmentation and inconsistent workflows. Advanced interdisciplinary, team-based care models incorporating structured panel management and proactive outreach may improve population-level glycemic outcomes while supporting evidence-based clinical decision-making.

Objective
To reduce the proportion of adult patients with poorly controlled diabetes (HbA1c >9%) through implementation of a structured, interdisciplinary diabetes panel management intervention within a primary care practice.

Methods
This quality improvement initiative was conducted in a large primary care practice participating in a value-based care model emphasizing population health management. Beginning in October 2024, a structured diabetes panel management pathway targeting patients with HbA1c >9% was implemented. Key components included interdisciplinary morning huddles; structured visit planning using patient-focused checklists prepared by care team before clinic to flag any barriers or gaps in care, medication reconciliation and Medical Assistant Tasklist forms to support laboratory completion, and follow-up; distribution of Provider Panel Report Cards summarizing practice-level diabetes metrics weekly; and monthly Hypertension and Diabetes Management Committee meetings to review population-level data and reinforce pathway adherence. The primary outcome was the proportion of patients with HbA1c >9%, tracked longitudinally.

Results
At baseline in October 2024, 32.4% of patients had HbA1c >9%. Following implementation, this proportion declined to 23.44% by February 2025. Modest fluctuations were observed during 2025 (April 25.07%, June 25.67%, August 26.59%, October 24.12%), temporally associated with onboarding of new clinicians. Despite these transitions, sustained improvement was observed, with rates decreasing to 22.5% in November 2025, 18.18% in December 2025, and 15.4% by mid-January 2026, representing a clinically meaningful reduction from baseline.

Conclusion
Implementation of a structured, interdisciplinary diabetes panel management pathway within an advanced team-based primary care practice was associated with sustained improvement in glycemic control among patients with poorly controlled diabetes. This population-based approach, supported by standardized workflows, data transparency, and interdisciplinary collaboration, is scalable and may improve chronic disease management across primary care settings.

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