Return to site

Diabetes Population Health Management @ Massachusetts General

Keywords: Diabetes, Population Health


Use of population health coordinators to optimize care for patients with diabetes


Blair Fosburgh MD


Victor Agbafe


Internal Medicine Associates at Massachusetts General Hospital, Boston, MA

Organizational Context

  • Massachusetts General Hospital Internal Medicine Associates is located in Boston, MA
  • One of sixteen primary care practices affiliated with Massachusetts General Hospital
  • The Internal Medicine Associates (IMA) is a large practice that is organized into interprofessional healthcare teams called “pods”
  • This diabetes-focused intervention is being rolled out at all primary care practices affiliated with Massachusetts General Hospital.
    • Notably, intervention implementation is led by each site’s population health coordinator and thus varies slightly from practice to practice, depending on the workflows in the practice.

Population Served

  • The Massachusetts General Hospital primary care practices serve a diverse patient clientele from a population and payer source perspective.
    • About 65% of patients who come to MGH IMA have commercial insurance, 30% have Medicare and 5% are on Medicaid. However, there are fewer non-English speaking patients than in other clinics within the Boston area.

Project Leadership

  • Dr. Blair Fosburgh, who serves as the Medical Director of IMA, worked with IMA's population health coordinator to implement the intervention

Project Tools and Components

  • MGH's IT team developed a data registry linked to the EMR by which population health coordinators could identify the following groups of people:
    • # of patients with diabetes within the site’s patient panel
    • % of patients in this group with uncontrolled diabetes (defined as HbA1c >7)
    • # and % of patients among those with diabetes overdue for health maintenance (e.g. HbA1C every 3 months, and blood cholesterol level every 6 months to 1 year)
  • The project team developed protocols for which pod team member the population health coordinator notifies when a particular test is overdue.
    • If a patient is overdue for blood pressure testing, the pod’s nurse has the responsibility of contacting the patient to come in for testing. 
    • For other tests, medical assistants contact patients.
    • Most patients are contacted by telephone, although some patients are contacted through the site’s EMR-enabled patient portal that was configured to send templated messages to individual patients with diabetes or groups of patients with diabetes.
  • Population health coordinators prepared an online, patient-targeted, video-based educational tool (Vidscripts) for health maintenance appointments. These videos emphasize the importance of health maintenance and routine screening tests in the care of patients with diabetes and are sent to patients prior to their screening appointments.
    • The MGH Primary Care Innovation Team and population health coordinators had previously worked with Vidscripts to determine relevant content for this tool.


  • Population health coordinators received training in group sessions which were led by physicians overseeing the intervention.


  • Epic Registry
  • Videos

Team Members

  • Physicians
  • MAs
  • RNs
  • Population health coordinator

Daily Workflow

  • On a regular basis, population health coordinators identify patients overdue for routine screening tests. They then identify the appropriate “pod” team member depending on the test that is overdue (described above). Patients are contacted via either phone or EMR to make an appointment.
  • Every time a physician sees a patient with diabetes they are reminded through an automated Epic alert which tests the patient is overdue for & what that patient’s latest diabetes care metrics are.
  • Once or twice a year, each physician sits down with their site’s population health coordinator to review and edit a care plan for each patient with uncontrolled diabetes in their panel.


  • ~$50,000
    • Main costs are the salaries of population health coordinators.
    • Paid for by Massachusetts General Hospital rather than individual practices.
    • On average, in the US, a population health coordinator is paid $42,5000.

Current Status

  • Intervention is ongoing, and has been integrated into standard clinical care


  • This intervention has brought about better care of diabetic patients.
    • Patients tend to feel positively about the intervention because they believe their physicians are thinking about them on a more consistent basis.
  • This intervention has indirectly enabled MGH Primary Care and MGH as a whole to be more competitive in securing risk-sharing contracts with payors.
  • Within the organization, the success of this intervention has helped to validate the need for and increase the budget for MGH Population Health Management 


  • On average, the patients involved in this intervention tend to do better at the end of the year in terms of diabetes metrics.
  • This intervention has benefited physicians by bringing in other team members to help them ensure their patients are up to date on recommended testing.
  • This intervention has helped staff members at the involved sites think about their patients even in between physical appointments.

Unique Challenges

  • There is a risk that some patients feel like they are being bothered by repeated contact attempts.
  • There is a risk that some members of the interprofessional team might feel like the population health coordinators are intruding upon their professional scope of practice.

Personnel Challenges

  • The IMA site is a large, busy practice and staff member buy-in can be an issue, particularly because this project has created added work. 
All Posts

Almost done…

We just sent you an email. Please click the link in the email to confirm your subscription!

OKSubscriptions powered by Strikingly