Display of fresh strawberries at a farmer's market

Physicians for a Healthy California (PHC) and the Network of Ethnic Physicians Network (NEPO)  partnered with the American Medical Association (AMA) to educate physicians and health care providers about identifying and managing prediabetes in their patient populations. 

Project Overview

To help prevent type 2 diabetes, the Center for Disease Control (CDC) and the AMA created a toolkit that health care teams can use as a guide to screen, test and act today by referring patients to in-person or online diabetes prevention programs. Tools will help your practice:

  • Engage your health care team
  • Engage patients
  • Incorporate Screening, Testing and Referral into your practice



Diabetes Care Coordination Team Care Model was a 2013 demonstration project that sought to lessen the burden of cardiovascular disease and improve outcomes for patients with type 2 diabetes.  The project worked to:

  • Develop the capacity of medical assistants to become key diabetes care team members utilizing PHC’s newly published Diabetes Care Coordination - Team Based Care Guide; 
  • Integrate the use of evidence-based medication protocols into practice; 
  • Use available data to manage patient populations and improve how care is planned and tracked and coordinated; and, 
  • Link patients to key resources such as Certified Diabetes Educators (CDEs), Chronic Disease Self- Management education, case management services, dietitians and other available community resources for long term self-management support.

Diabetes Care Coordination - Team Care Model

The goals of the project were to:

  • Improve the quality of care provided to diverse patient populations with diabetes
  • Encourage early identification and management of diabetes and prediabetes
  • Effectively prevent and manage cardiovascular complications
  • Strengthen the capacity of patients to manage their diabetes and prevent cardiovascular complications
  • Improve the capacity of medical assistants to serve as effective diabetes care team members
  • Link patients to key self-management resources such as community resources, CDEs and/or case management services

Physician Resources