The Diabetes Pilot Project - Core Health Partners, CHP

The Diabetes Pilot Project

Take Control of this Disease, Or it Will Take Control of You...


Our Clinic to Community Model of Service Started with the YMCA  

“More people die of diabetes than breast cancer and AIDS combined,” said Marrero, who is himself an insulin-dependent type 1 diabetic. “We’re not a sexy disease —people don’t flame out, they rust out. Education is key, said Marrero. If you’re diagnosed with this, you have to have a master’s degree overnight.”

Dr. David Marrero 2016 American Diabetes Association President

Dr. David Marrero is a Ph.D. psychologist and former president of the American Diabetes Association. Marrero is credited in developing a YMCA’s pre-Diabetes Prevention Program, (Y-DPP) that was awarded the Health Care Innovation Award by the Center for Medicare and Medicaid Innovation (CMMI). These awards provided  nearly $12 million over three year period for the Y to conduct a demonstration project in 17 communities across the nation.  Marrero’s YMCA’s Diabetes Prevention Program grew to 10,000 Medicare enrollees, factoring a major cost savings to the nation’s largest healthcare payer.  The Y-DPP was adopted to become the National diabetes platform for the Ys across the nation. Today the Y-DPP has expanded to over 200 YMCA who proudly offer Marrero’s prevention program.

Over the past 60 years in the US, the incidence of diabetes increased more than sevenfold, making it one of the country’s most troubling health threats. One in 3 adults in the United States, about 100 million people, are living with diabetes or prediabetes, according to the Center for Disease Control and Prevention (CDC). Diabetes can cause heart disease, kidney failure, and blindness, and costs the US health care system and employers $237 billion every year. On average, people with diagnosed diabetes have medical expenditures approximately 2.3 times higher than what would be in the absence of diabetes.  The cost of care for people with diabetes now accounts for  1 in 4 health care dollars spent in the United States. Care for a person with diabetes now costs an average of $16,752 per year. A new case of diabetes is diagnosed every 21 seconds and the disease is credited with killing someone every eight seconds.


Successful prevention and management of diabetes often require efforts that go beyond traditional clinical care, particularly in underserved and socially disadvantaged populations. Bringing clinical services into the community setting is a best practice for addressing chronic disease.  This model of service is is evidence-based and offers promising strategies for intervening in early life, in the community, and at the nexus between the community and clinical settings.

A successful models requires dedicated expertise and support from clinical team members who work alongside social workers, such as a non-profit who have an expertise in evaluating social needs, connecting to resources, and following up to ensure successful community connection.  Hospitals, traditional medical clinics and independent physicians become the referral base to Core Health Partners (CHP) who specializes in bringing the model of service to community centers and communicate the results back to the referring entity. CHP takes the time to interfaces with the community center leadership and staff by serving on committees that are designed to best assure the community center/ non-profit staff has an understanding for the disease and the environment is socially welcoming. The YMCAs are a natural partner for CHP’s clinic to community model.   

Diabetes is a chronic disease that requires daily management and healthy lifestyle choices to maintain
normal blood glucose levels. The Diabetes Alliance Network has built an infrastructure that supports implementing the best and newest trends in caring for the disease and maintaining positive lifestyle changes. The structure of service created by the members of the Diabetes Alliance Network facilitates a clear communication line to the best in the field of diabetes education and research. The structure offer
the ability to communicate health and social needs between providers and community resources.

Through the Diabetes Alliance Network (DAN) created a single clinical provider model (Core Health Partners) so that the program has the ability to measure outcomes and make appropriate adjustments to the curriculum lesson or techniques utilized in delivering a high level of quality service in the area of diabetes management. Select national partners in the Diabetes Alliance assure the non-profit community center is ready and able to appropriately serve this patient population. The Core Health Partners medical practitioners participating in the model  focus their continued education on the newest and best methods of diabetes self management techniques and methods. This assures CHP is at the forefront of diabetes care.

The Diabetes Alliance Network and Core Health Partners recognize the rich history of the Y’s and their ability to make a difference with some of nation’s most pressing issues. Core Health Partners was created from leaders from within the Y moment.  We are excited to pilot a clinic to community diabetes program through the YMCA because we know it will not only make a positive impact to the individuals participating in the program as patients, it will improve their quality of life for their families and ultimately benefit the community.

The YMCA engages 9 million youth and 13 million adults each year in the U.S.  The Y aims to improve the nation’s health and well-being by providing programs and activities that promote wellness, reduce risk for disease and help others reclaim their health. The Y’s long-standing track record and on-the-ground presence necessary to address national health issues that benefit and community life, aligns with the Diabetes Alliance Network’s goal of providing a positive impact on diabetics participating in diabetes self-management and education. 

The Y is the perfect platform because of they are accessible to all people and they offer financial assistance to individuals and families who cannot afford membership. The programs offered at the YMCA and everything else the Y does are in service of making  communities better. 

Layering CHP’s  pilot projects with advanced community support from the National Wellness Institute assures; the physicians,  the YMCA staff, and the community at large are prepared for the clinic to community.

Core Health Partners was the brainchild of  former the YMCA employees who opened the nation’s first healthy living center (Clive, Iowa) and senior YMCA leadership who wanted to advance the Ys ability to bill medical insurance.  Our model of medical service differs from most across the country, as ours is built with intentional integration with the YMCA staff. Our model places the  importance on education and lifestyle change. CHP’s model is in collaboration with the Diabetes Alliance Network (DAN).  Through this partnership the community will have access to clinical medical experts help guide an advanced wellness program that is proven to grow membership, revenues and strengthen the community that the YMCA serves.  We are patient centered but we also understand the importance of continuing an education action plan for the YMCA staff, the caregivers, and the community.  The National Affiliates of Dan include the National Wellness Institute (NWI) and the University of Florida Diabetes Institute.  NWI represents the nation’s oldest accrediting agencies in the area of community wellness with strong experience in engaging statewide and national wellness projects. They will be joined by world renowned experts in the area of diabetes  from the University of Florida Diabetes Institute (UFDI).


Stronger Together, the YMCA joins the Alliance of Partners in Support of Diabetes

Roger Ludwig, the father of child with type 1, had a vision to expand YMCA services beyond the pre-diabetes prevention. Ludwig, a former YMCA volunteer leader, understood the YMCA’s rich history of preventative health programs. Roger a well known philanthropist representing the Weny Charitable Trust wanted  a program that included helping those who live with Type 1, or Type 2 diabetes.

The Weny Charitable Trust provided the original seed-money to design a unique diabetes education program for the YMCAs.  The uniqueness of the Diabetes Self-Management & Education (DSME) program is integration to deliver it with the walls of a YMCA’s and the expertise delivered through the individual partners.

Help a Diabetic Child (HADC) a 501c3 non-profit jointly participated in the DSME’s design alongside; former YMCA employees, and clinical practitioners from Core Health Partners. Their passion and enthusiasm to strengthen the community through partnerships.  Their passion became contagious and expert agencies informally joined their affiliation.  By 2018 the collaborative momentum led to the Diabetes Alliance Network (a separate Non-profit), formalizing the agencies in support of those diagnosed with diabetes.   These alliance partners now includes the National Wellness Institute (NWI), who is well positioned as a worldwide voice of the diabetes wellness movement.  The collaborative work of DAN has led to a unique delivery mechanism that sustains diabetes education and program services in community settings.

By July 2019 the unique diabetes education program designed for YMCAs was complete. on July 1st 2019  The Diabetes Alliance Network, Core Health Partners and the YMCA of South Collier earned Recognition status by the American Diabetes Association (ADA) for their efforts.   Medicare and most all other private insurances cover the cost of the DSME program delivered through the YMCA. Core Health Partners proudly serves as the preferred clinical provider for this program. The program is under the oversight and review by the Diabetes Alliance Network. The quality outcomes are reviewed by and exclusive academic medical advisors group from the University. Through DAN’s review process, updates and new technology are able to be placed into the DSME lessons, as well as access to University medical experts should there be questions on this complex disease. 

Persons interested in having their Insurance cover the Diabetes Self Management and Education (DSME) courses should print this PDF Medical Referral form and take it to their physician.

The Diabetes Alliance Network’s (DAN) diabetes education program is a modular model that is designed to be adapted for different cultures, populations and individuals’ needs. The patent pending, modular 5-touch DAN (DSME) program format is created in a manner that allows the program to be expanded to other YMCAs and community centers Nationwide.

The DAN education program is a modular model that is designed to be adapted for different cultures, populations and individuals’ needs. The modular 5-touch DAN (DSME) program format is able to be easily expanded to other YMCAs and community centers Nationwide.

The DAN program is patent pending. Persons interested in learning how DAN could benefit your community, or YMCA should contact the Senior Executive VP for Advancement & Partnerships, or the Community Liaison for Chronic Disease Programs & Partnerships.

Roger Ludwig, is shown in the photo standing over Dr David Marrero, the former president of the American Diabetes Association. Marrero is credited with developing the National YMCA's Pre-Diabetes Prevention Program (Y-DPP).

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