Delaware Boosts Diabetes Prevention Referrals Using EHR and Academic Detail

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Submission Date: September 2021

State/Territory Submitted on the Behalf of: Delaware

States/Territories Involved: Delaware

Funding Source: CDC

CDC Funding:


Public Health Issue:

As of 2019, approximately 12.8% of Delawareans age 18 and older, more than 98,700 adults, reported they had been diagnosed with diabetes, according to the Delaware Behavioral Risk Factor Survey. Only 11.8% of Delaware’s population that had not been diagnosed with diabetes, more than 75,000 residents, reported being diagnosed with prediabetes. Based on national data, 1 in 3 adults have prediabetes, which puts them at increased risk for developing type 2 diabetes, but 90 percent of them do not know it. This suggests there are more than 230,000 adults in Delaware who have prediabetes but do not know it.

The Delaware Diabetes and Heart Disease Prevention and Control Program (DHDPCP), housed within the Delaware Department of Health and Social Services (DHSS) Division of Public Health, is a public health program that supports evidence-based lifestyle changes focusing on healthy eating and physical activity for adults who are at risk for developing type 2 diabetes.

Since 2000, the DHDPCP has been committed to reducing the burden of diabetes among Delawareans at high risk by utilizing sustainable community-clinical partnerships to provide opportunities for primary prevention emphasizing healthy lifestyle change.

A goal for the DHDPCP is to expand the availability and coverage of Centers for Disease Control and Prevention (CDC) led National Diabetes Prevention Program (National DPP) to communities with a high burden of risk factors for diabetes. The DHDPCP seeks to identify persons with prediabetes, provide them with information on prediabetes and the risk for developing type 2 diabetes, and enroll them into the National DPP lifestyle change program.

Program Action:

To address Delaware’s growing risk for developing type 2 diabetes, the DHDPCP contracted with non-profit organization Quality Insights to help engage healthcare practices as part of grant work funded by the CDC. In addition to managing the contract, the DHDPCP works with Quality Insights to conceptualize diabetes prevention efforts in scaling and expanding the reach of the National DPP.

Quality Insights features all National DPP information on a dedicated diabetes prevention webpage that serves as a resource to health care providers across the state.

In an effort to identify persons with prediabetes and increase National DPP enrollment, Quality Insights engaged 10 health system sites in a National DPP referral letter campaign.

The 10 sites that participated in the letter campaign all utilized electronic health records (EHR) that remind providers and the care team to discuss prediabetes and the National DPP referral letter with qualifying patients. The EHRs are also able to designate the National DPP provider (YMCA of Delaware) as a referral caregiver. Doing so establishes a discrete record of the patient referral in the EHR.

The practice with the most referrals received a Diplomat for Diabetes Prevention award. The National DPP provider (YMCA of Delaware) calculates the number of referrals per provider. The practice that received the award has continuously referred patients to the program for many years, and prediabetes is a topic that the physicians discuss with patients often.

Quality Insights has a prediabetes educational module that is discussed with all practices engaged in the program. Content contained within the module is reinforced in delivery of four weekly emails.

Quality Insights developed a Diabetes and Prediabetes Academic Detailing (AD) provider education module and piloted the program with two practices. AD is one-on-one provider education delivered by trained clinical educators. The goal of the AD program is to share current, evidence-based information in an effective and convenient format tailored to provider needs and preferences. Providers receive a Diabetes Toolkit detailing aid for the program.

Available provider education topics include current state and national statistics; American Diabetes Association recommendations on screening, early detection, and treatment; coding for prediabetes; and referrals to CDC-recognized lifestyle intervention programs, including the National DPP. Practices are provided with a pocket guide to help improve their screening and testing rates.

Working with Quality Insights, an online National DPP provider (Yes Health) partnered with eight practices to promote online National DPP support and coaching to their patients. Each practice had its own promotional brochure for the program.


The DHDPCP partnership with Quality Insights has led to memoranda of understanding with 112 healthcare practices, representing one-third of the patients in Delaware, and increased access to the National DPP.

Quality Insights engaged 10 health system sites with 35 providers caring for 40,956 patients in the National DPP referral letter campaign. The 10 sites included three Federally Qualified Health Centers (FQHC) and four healthcare systems and reached all three counties in Delaware.

Through the National DPP referral letter campaign, a total of 5,613 patients were referred to the National DPP over two years.

The Diabetes and Prediabetes Academic Detailing program reached a total patient population of 5,000 through the pilot with three providers at two practices. One of the pilot practices, a FQHC with two additional locations, has requested another session for their other providers, to be held later in 2020. For 2020-2021, Quality Insights will provide AD for five additional practices.

Program Areas:

Diabetes, Epidemiology and Surveillance

State Contact Information:

Don Post
Delaware Division of Public Health, Bureau of Chronic Disease

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