St. Charles Health System

Diabetes costs an estimated $3 billion each year in Oregon due to higher health care costs and reduced productivity (Oregon Health Authority, 2015). A person with uncontrolled diabetes is at risk of serious health complications such as heart disease, kidney disease and limb amputations.

Improving glycemic control has proven to help reduce readmissions and ED utilization rates. Evidence has shown that for every 1 point reduction in HbA1c, the risk of developing eye, kidney or nerve disease is reduced by 40 percent, while the risk of heart attack is reduced by 14 percent (HRSA, 2012). Yet many patients fail to meet treatment goals for lowering HbA1c. Issues related to patient compliance and medication adherence are associated with adverse clinical outcomes for patients with diabetes. Furthermore, many older patients with diabetes face additional barriers to disease management, including cognitive dysfunction, depression, physical disabilities and polypharmacy.

Clinic visits, even when a patient is compliant with provider recommendations, do not provide enough time to adequately address the many complicated issues related to diabetes management such as nutrition therapy, insulin management , behavioral health and health literacy needs. The St. Charles Mobile Care Clinic model would allow caregivers to spend more time helping patients with pharmaceutical review and medication management, nutritional needs, lifestyle modifications, motivational interviewing and other services necessary for patients to gain self-management skills and work through the necessary stages of change. Through assessing a patient’s a physical environment and with regular outreach, the care team can gain understanding of a patient’s barriers to improved health and better individualize a patient’s plan of care.

The St. Charles Mobile Care Clinic will provide ongoing clinical support to help patients with diabetes gain in self-management skills, identify barriers to care and make lifestyle modifications to improve health outcomes.  The mobile clinic borrows concepts from outreach and telehealth programs that have proven successful in helping vulnerable patients become more engaged in their own care while also enabling providers to make timely adjustments to treatment plans. The one-year pilot will serve patients from St. Charles Family Care in Prineville, where Crook County residents accounted for one of the highest diabetes rates in the state (Oregon Health Authority, 2017). After the trial period, St. Charles evaluated processes and outcomes with the intent to expand the clinic to serve patients across the system.


Oregon Health Authority (2015). Oregon Diabetes Report. Retrieved from

U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Diabetes Poor Control. Retrieved from