Chronic Disease Pledge Bright Spot: Group Health Cooperative of South Central Wisconsin’s Diabetes Improvement Team

June 17, 2025

Group Health Cooperative of South Central Wisconsin (GHC-SCW) has observed sustained improvement in A1c control among its members over several years. Building on that success, GHC-SCW set a 2025 organizational goal to exceed the HEDIS 90th percentile for Glycemic Status Assessment for Patients with Diabetes (GSD) via strategic planning efforts.

To support the goal of improving A1c outcomes, GHC-SCW leans on its Diabetes Improvement Team (DIT), which consists of key clinical and administrative stakeholders. Due to GHC-SCW’s integrated structure, DIT members provide key insights and ideas to develop new projects and workflows. Team members then give feedback on existing work, which allows DIT to continuously add value to the care that GHC-SCW clinical staff delivers to patients.

GHC-SCW is particularly proud of two projects the DIT has developed in recent years. Both projects have demonstrated an improvement in A1c control for patient participants and have been well received by patients.

The first project GHC-SCW initiated was its Diabetes Support Group. This group met once monthly for six months to discuss the seven ADCES Diabetes Self-Care Behaviors: Healthy Coping, Healthy Eating, Being Active, Taking Medication, Monitoring, Reducing Risk and Problem Solving. Subject matter experts facilitate discussions specific to their discipline, including behavioral health, nutrition, physical therapy, pharmacy, primary care, urgent care and eye care. The purpose of the group is to offer education and peer support to participants. It provides a safe space where participants can ask questions and learn from other members who struggle with the daily challenges of living with diabetes. GHC-SCW partnered with a local food pantry to provide each participant with a box of diabetes-friendly produce, at no cost, to further support participants seeking to make positive changes.

GHC-SCW shifted this program to a virtual format during the pandemic. Participants in the Virtual Diabetes Support Group received the same education, support and food boxes. Surveys found participants preferred the virtual option, so facilitators continued it in this format.

Organizers shortened the length of the program and moved from a monthly meeting to bi-weekly sessions after observing a decline in participation in 2024. The rebranded Diabetes Boot Camp now allows GHC-SCW to host two programs per year and serve more patients.

In 2024, the DIT implemented the second improvement strategy, offering Diabetes Focus Visits (DFVs). These visits allow patients to meet 1-on-1 with a GHC-SCW Clinical Pharmacist and cover all diabetes-related topics, such as medications, preventative care, diabetes distress, CGMs and more. These visits were made possible through the expansion of a Clinical Pharmacy Collaborative Practice Agreement, training with GHC-SCW’s internal Clinical Health Education team, patient outreach from the Quality Management department and advocacy by members of the DIT.

The DFV results are compelling. Of the patients who completed a DFV in 2024 and have had a follow-up A1c, the average decline in A1c is 1.0 percent. Those whose baseline A1c was ≥ 8, the average A1c change is 2.1 percent. While those with a baseline A1c ≥ 9, the average decline is 3.0%. Aside from improved A1c outcomes, 98% of patients surveyed indicated that they were either “satisfied” or “very satisfied” with their visit, and 96% indicated that they would recommend a DFV to a fellow GHC-SCW patient. Due to the DFVs’ success and positive feedback, they have continued in 2025.

As GHC-SCW looks into the future, it hopes to build on the success of existing programs like the Diabetes Boot Camp and Diabetes Focus Visits while exploring new strategies with the help of the Diabetes Improvement Team. The team is excited to leverage Epic technology to expand patient-reported data and improve patient education. Also, DIT would like to continue to grow the number of patients who utilize CGMs to help more people feel more empowered in their care.