Arizona Diabetes Strategic Plan
2008-2013
Arizona Diabetes Coalition

Office of the Director
150 North 18th Avenue, Suite 500
Phoenix, Arizona 85007-2670

JANET NAPOLITANO, GOVERNOR
JANUARY CONTRERAS, DIRECTOR, ACTING

(602) 542-1025
(602) 542-1062 FAX
August 4, 2008
Dear Arizona Residents,
Diabetes is a serious and costly disease in Arizona. The number of people with diabetes in Arizona grows each year. In
fact, since 1990 the prevalence of diabetes in Arizona has doubled from 4 percent to 8.5 percent in 2006.
We know that type 2 diabetes, which is the most common type of diabetes, can be prevented and that people with
diabetes can live healthy and long lives with the proper care. Through education, increasing access to care, and other
public health strategies, we have a great opportunity to work with our partners in Arizona to reduce the burden of
diabetes on individuals, families, and communities.
The Arizona Diabetes Strategic Plan is the first plan in Arizona to address diabetes from a public health perspective for the
entire State. It uses public health strategies to address opportunities for improvements in healthcare systems, the diabetes
workforce, community partnerships, and local and organizational policies.
We have great hope that by working together with partners throughout Arizona that we will be able to reduce the
prevalence rate of diabetes and improve the lives of people living with diabetes in Arizona. We are proud to be a part of
the Arizona Diabetes Coalition.
Sincerely,

January Contreras
Acting Director
Arizona Department of Health Services

Arizona Diabetes Strategic Plan, 2008 - 2013

A Message from the Chair of the Arizona Diabetes Coalition
The Arizona Diabetes Coalition members worked over the past year to develop this strategic plan. It was a true
collaborative effort with many leaders and experts in diabetes coming together to address how we can combat diabetes in
Arizona. We are grateful for the input provided by individuals and families that live day in and day out with this
devastating disease. These men, women, and children are the reason why we are all committed to the fight against
diabetes. We realize it is going to take many people and many partners to make changes to improve the lives of people
at risk for and living with diabetes in Arizona. This strategic plan focuses on four areas for change:
1.
2.
3.
4.

Primary prevention of type 2 diabetes;
Quality care and treatment with strategies focused on patients;
Quality care and treatment with strategies focused on providers; and
Public policy.

This strategic plan provides an opportunity to improve the burden of diabetes in Arizona. Many of our strategies deal with
partnerships, because we realize that we cannot do this alone. By leveraging our efforts with the efforts of other people
and organizations from different areas we can work together to make positive changes. We can make a difference.
Together with partners throughout the State we can make a significantly greater difference in the quality of the lives of
people with diabetes and their families than any of us could by working alone. Using a coordinated and collaborative
approach and maximizing our resources will create a healthier Arizona.

Donna Zazworsky, MS, RN, CCM FAAN
Chair, Arizona Diabetes Leadership Council and Coalition
Director of Network Diabetes and Outreach
Carondelet Health Network

Arizona Diabetes Strategic Plan, 2008 - 2013

Table of Contents
Acknowledgements ....................................................................................................................................................v
Background ..............................................................................................................................................................2
Types of Diabetes................................................................................................................................................2
Treating Diabetes ................................................................................................................................................3
Prevention or Delay of Diabetes ..........................................................................................................................3
Prevention of Diabetes Complications ..................................................................................................................3
Description of the Problem ........................................................................................................................................4
Diabetes Prevalence ............................................................................................................................................5
Health Care Access ............................................................................................................................................6
Cost of Diabetes ................................................................................................................................................6
Deaths among persons with Diabetes ..................................................................................................................7
Diabetes in Persons Less than 18 years of Age. ....................................................................................................7
Complications of Diabetes ..................................................................................................................................7
Development of the Strategic Plan ............................................................................................................................9
Background ........................................................................................................................................................9
Methods ..........................................................................................................................................................10
Arizona Diabetes Strategic Plan ..............................................................................................................................13
Priority Area 1: Primary prevention of type 2 diabetes ........................................................................................15
Priority Area 2: Quality care and treatment with strategies focused on people with diabetes ................................19
Priority Area 3: Quality of care and treatment with strategies focused on health care providers ............................22
Priority Area 4: Public policy ..............................................................................................................................26
References ..............................................................................................................................................................28
Abbreviations..........................................................................................................................................................29

Arizona Diabetes Strategic Plan, 2008 - 2013

ACKNOWLEDGEMENTS
This plan would not have been possible without the support, dedication, and guidance of the Arizona Diabetes Leadership
Council. Council members developed the strategies outlined in this plan and provided valuable feedback on the draft
report. Donna Zazworsky, Chair of the Arizona Diabetes Leadership Council, was instrumental in leading this effort and
working with the larger Arizona Diabetes Coalition to gather input on strategies and implementation of the plan at the
2007-2008 coalition meetings.
Staff from the University of Arizona Mel and Enid Zuckerman College of Public Health facilitated the development of this
plan. We are thankful for their guidance for keeping us focused and ensuring that our strategies will meet desired
outcomes.
A special thanks to the Arizona Diabetes Coalition members and Committee (Advocacy, Education, and Surveillance)
Chairs for their input. We appreciate the valuable work of members who spent time providing feedback and guidance on
the strategies. We also thank the Bureau of Chronic Disease Prevention and Control staff, especially the Arizona Diabetes
Program, for writing, reviewing, editing, and providing valuable comments on the plan.

Arizona Diabetes Leadership Council Members
Chair
Donna Zazworsky, MS, RN, CCM, FAAN
Carondelet Health Network
2007-2008

Kim Elliot, PhD
Arizona Health Care Cost Containment System
2008
Melissa Spezia Faulkner, DSN, RN, FAAN
The University of Arizona College of Nursing
2008

Chair-E
Elect
Scott Endsley, MD, MSc
Health Services Advisory Group
2007-2008

Pam Ferguson
American Heart Association
2007-2008

Advocacy Committee Chair
Sue Hendershott, MSN, RN, CDE
Caremark
2007-2008

Robert Guerrero, MBA
Arizona Department of Health Services
2007-2008

Surveillance Committee Chair
Zeenat Mahal, MBBS, MS
InterTribal Council of Arizona, Inc.
2007-2008

Kimberly D. Harris-Salamone, PhD
Health Services Advisory Group
2008

Education Committee Chair
Linda Parker, RN
Carondelet Health Network
2008

Trish Herrmann, MS, RD
Arizona Department of Health Services
2007-2008
Darlene Horst, BSN, RN, CDE
Mt. Graham Regional Medical Center
2008

Betty Page Brackenridge, MS, RD, CDE
Diabetes Management & Training Centers, Inc.
2007

Arizona Diabetes Strategic Plan, 2008 - 2013

v

Arizona Diabetes Leadership Council Members
Valerie Jones
Juvenile Diabetes Research Foundation
2007

Bobbi Presser, MPH
Scottsdale Healthcare
2007-2008

Beth R. Malasky, MD
Native American Cardiology
University Medical Center
2007-2008

Sara Sparman
Juvenile Diabetes Research Foundation
2008
Lisa Staten, PhD
University of Arizona
Mel & Enid Zuckerman
College of Public Health
2007-2008

Suzanne Miller
American Diabetes Association
2007-2008
Anita Murcko, MD, FACP
Arizona Health Care Cost Containment System
2007-2008

Christine Winters, MS, RD, CDE
Yuma Regional Medical Center
2007

Education Subcommittee Chairs
Public Health Chair
Leticia Martinez, RD, MPH, MS, BC-ADM
El Rio Health Center
2008
Hospital Chair
Debby Beechey
Sanofi-Aventis
2008
Provider Chair
Scott Endsley, MD, MSc
Health Services Advisory Group
2008
Patient Chair
Linda Parker, RN
Carondelet Health Network
2008

Arizona Diabetes Strategic Plan, 2008 - 2013

vi

University of Arizona Mel and Enid Zuckerman
College of Public Health
Erin Peacock, MPH
Adriana Cimetta, MPH
Kim Fielding
Anneke Jansen, MPH
Ralph Renger, PhD

Arizona Diabetes Program Staff
Trish Herrmann, MS, RD
Carmen Ramirez
Alexandra Ikeda
Kai-Ning Khor

Arizona Diabetes Strategic Plan, 2008 - 2013

vii

Our Vision
A state without diabetes

Our Mission
To reduce the health, social, and economic burden of diabetes in Arizona

BACKGROUND
Types of Diabetes1
Gestational Diabetes1-44

Diabetes mellitus is a group of diseases characterized by
high levels of blood glucose resulting from defects in
insulin secretion, insulin action, or both. Diabetes can be
associated with serious complications and premature
death, but people with diabetes can take steps to control
the disease and lower the risk of complication.

Gestational diabetes mellitus (GDM) develops in
approximately 7 percent of all pregnancies. Immediately
after pregnancy, 5 to 10 percent of women with
gestational diabetes are found to have diabetes, usually
type 2. GDM occurs more frequently in African Americans,
Hispanic/Latino Americans, American Indians, persons
with a family history of diabetes, and among women who
are obese. Women who have had GDM are at increased
risk for developing type 2 diabetes later in life. Between 40
and 60 percent of women with a history of GDM
developed diabetes in the future. The children of women
with a history of GDM are at an increased risk for obesity
and diabetes compared to other children.

Type 1 Diabetes
Type 1 diabetes was previously called insulin-dependent
diabetes mellitus (IDDM) or juvenile-onset diabetes. Type 1
diabetes may account for 5 percent to 10 percent of all
diagnosed cases of diabetes, and usually appears in
childhood or adolescence, hence the more familiar term
"juvenile diabetes". The risk factors are less defined for
type 1 diabetes than for type 2 diabetes, but autoimmune,
genetic, and environmental factors are involved in the
development of this type of diabetes.

Pre-D
Diabetes
Pre-diabetes is a term used for people who are at
increased risk of developing type 2 diabetes, heart
disease, and stroke. People with pre-diabetes have
impaired fasting glucose (IFG) or impaired glucose
tolerance (IGT). IFG is diagnosed when fasting blood
glucose level is elevated (100 to 125 mg/dl) after an
overnight fast, but is not high enough to be classified as
diabetes. IGT is a condition in which the blood sugar level
is elevated (140 to 199 mg/dl) after a 2-hour oral glucose
tolerance test, but is not high enough to be classified as
diabetes.5 Most recent estimates from 2003-2006 indicate
that 26 percent of all US adults age 20 years and older
had IFG.1 Applying this percentage to the entire US and
Arizona population estimates, 57 million Americans and
over 1.1 million Arizonans had impaired fasting glucose in
2006.6

Type 2 Diabetes
Type 2 Diabetes was previously called non-insulin
dependent diabetes mellitus (NIDDM) or adult-onset
diabetes. Type 2 diabetes may account for about 90
percent to 95 percent of all diagnosed cases of diabetes,
and usually doesn't develop until after age 40. Risk factors
for type 2 diabetes include older age, obesity, family
history of diabetes, prior history of gestational diabetes,
impaired glucose metabolism, physical inactivity, and
race/ethnicity. African Americans, Hispanic/Latino
Americans, American Indians, and some Asian Americans
and Pacific Islanders are at particularly high risk for type 2
diabetes.

Other Types
Other types of diabetes result from specific genetic
syndromes, surgery, drugs, malnutrition, infections, and
other illnesses. These types of diabetes may account for
one percent to five percent of all diagnosed cases of
diabetes.1

Arizona Diabetes Strategic Plan, 2008 - 2013

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Treating Diabetes
Blood pressure control

To survive, people with type 1 diabetes must have insulin
delivered by injections or a pump. Many people with type
2 diabetes can control their blood glucose by following a
careful diet and exercise program, losing excess weight,
and taking oral medication. Many people with diabetes
also need to take medications to control their cholesterol
and blood pressure. Diabetes self-management education
is an integral component of medical care. Among adults
with diagnosed diabetes, 13 percent take both insulin and
oral medications, 14 percent take insulin only, 57 percent
take oral medications only, and 16 percent do not take
either insulin or oral medications.1

Blood pressure control can reduce cardiovascular disease
(heart disease and stroke) by approximately 33 percent to
50 percent and can reduce microvascular disease (eye,
kidney, and nerve disease) by approximately 33 percent.
In general, for every 10 millimeters of mercury (mm Hg)
reduction in systolic blood pressure, the risk for any
complication related to diabetes is reduced by 12 percent.
Control of blood lipids

Prevention of Diabetes Complications

Improved control of cholesterol or blood lipids (for
example, HDL, LDL, and triglycerides) can reduce
cardiovascular complications by 20 percent to 50 percent.

Diabetes can affect many parts of the body and can lead
to serious complications such as blindness, kidney
damage, and lower-limb amputations. Working together,
people with diabetes and their health care providers can
reduce the occurrence of these and other diabetes
complications by controlling the levels of blood glucose,
blood pressure, and blood lipids and by receiving other
preventive care practices in a timely manner.

Preventive care practices for eyes, kidneys, and feet
Detecting and treating diabetic eye disease with laser
therapy can reduce the development of severe vision loss
by an estimated 50 percent to 60 percent.
Comprehensive foot care programs can reduce
amputation rates by 45 percent to 85 percent.

Glucose control

Detecting and treating early diabetic kidney disease by
lowering blood pressure can reduce the decline in kidney
function by 30 percent to 70 percent. Treatment with ACE
inhibitors and angiotensin receptor blockers (ARBs) are
more effective in reducing the decline in kidney function
than other blood pressure lowering drugs.

Research studies in the United States and abroad have
found that improved glycemic control benefits people with
either type 1 or type 2 diabetes. In general, for every 1
percent reduction in results of A1C blood tests (e.g., from
8.0 percent to 7.0 percent), the risk of developing
microvascular diabetic complications (eye, kidney, and
nerve disease) is reduced by 40 percent.

Arizona Diabetes Strategic Plan, 2008 - 2013

3

DESCRIPTION OF THE PROBLEM
Diabetes Prevalence*

Prevalence of Diabetes by Race/Ethnicity1

In 2007, 7.8 percent, or 23.6 million, people of all ages
in the U.S. have diabetes (diagnosed and undiagnosed).1
This is a 37 percent increase in diabetes prevalence since
2000. Arizona has seen a 44 percent increase in adults
with diabetes from 2000 through 2006, with prevalence
rising from 5.9 percent to 8.5.7 The prevalence of persons
with diabetes in Arizona has more than doubled since
1990 (see Figure 1). An estimated 385,741 persons aged
18 years and older in Arizona reported to have diabetes in
2006.6,7 These numbers do not account for undiagnosed
diabetes, which is estimated to be one-third of all people
with diabetes, bringing the total number of people with
diabetes to about 513,000 (11.3 percent).8

The total prevalence of diabetes among Native Americans,
African-Americans, or Asians is not available in Arizona
because of small sample sizes of these groups in the
Behavioral Risk Factor Surveillance System (BRFSS).
Hispanic or Latino Americans make up almost one-third of
the Arizona population. In Arizona, 9.2 percent of
Hispanics have diabetes whereas 7.8 percent of nonHispanic Whites have diabetes.7 Nationally, the prevalence
of diabetes is also higher among Hispanics (10.4%) than
non-Hispanic Whites (6.6%). More than five percent of the
population in Arizona is Native American, a group also
more likely to develop diabetes than non-Hispanic Whites.
The national estimate for diabetes prevalence among
Native Americans and Alaska Natives is 16.5 percent, a
prevalence almost three times as high as those of nonHispanic Whites. African Americans make up 3.9 percent
of the Arizona population. Nationally, the prevalence of
diabetes among Blacks (11.8%) is almost twice that of nonHispanic Whites. Asian Americans and Pacific Islanders
make up about 2.6 percent of the population in Arizona.
Nationally, the prevalence of diabetes among Asians is
also higher (7.5%) than that of non-Hispanic Whites.

Figure 1. Prevalence of Diagnosed Diabetes in Persons Aged 18 years and older in Arizona, BRFSS, 1990-2006.

* In some cases, we do not have enough data to report Arizona statistics. Unless otherwise specified, the data in this report uses
National data.

Arizona Diabetes Strategic Plan, 2008 - 2013

4

Prevalence of Diabetes by Sex7

Prevalence of Diabetes by Level of Education and Income7

National BRFSS 2006 data indicates that prevalence of
diabetes is higher in males (8.0 percent) than females (7.2
percent). Arizona also reflects this national trend with 9.4
percent of males compared to 7.7 percent of females
reporting to have diabetes.

According to BRFSS data, the prevalence of diagnosed
diabetes is higher in populations with lower levels of
education (Table 2). In Arizona, 11.3 percent of adults
without a high school diploma have diabetes compared to
6.2 percent of adults with a college diploma. In addition,
individuals reporting lower income levels have increased
prevalence of diabetes. In Arizona, 15.2 percent of adults
with annual incomes less than $15,000 have diabetes
whereas 6.1 percent of adults with annual incomes over
$50,000 have diabetes.

Prevalence of Diabetes by Age
The prevalence of diabetes increases with age (Table 1).
Twenty-three percent of Americans aged 60 years and
older have diabetes, compared to 10 percent of Americans
aged 20 years and older.1 The Arizona BRFSS data
indicates aging adults, especially above the age of 55, are
at higher risk than adults between the ages of 18 and 54.

Table 1: Prevalence of Diagnosed Diabetes by Age Group in Persons 18 and Older in Arizona, BRFSS, 2000-2006.
18 - 34 Years

1.4%

35 - 44 Years

3.9%

45 - 54 Years

8.5%

55 - 64 Years

11.4%

65+ Years

14.7%

Table 2: Prevalence of Diagnosed Diabetes by Education Level in Persons 18 years and older, BRFSS, 2006
Level of Education

U.S. (including DC and territories)

Arizona

No High School Diploma

12.9%

11.3%

High School Graduate

8.9%

9.5%

Some College

7.7%

8.8%

College Graduate +

5.4%

6.2%

Arizona Diabetes Strategic Plan, 2008 - 2013

5

Health Care Access

Cost of Diabetes

Health care access is critical for persons with diabetes.
Persons with diabetes are disproportionately affected by
several complications, including heart disease, stroke,
amputations, kidney disease, eye disease, neuropathy, and
depression.1 According to National BRFSS data, 14.5
percent of persons 18 years and older reported not having
health care coverage in 2006. In Arizona, Hispanics have
a much higher percentage of reporting no health
insurance, 19.9 percent, versus 11.5 percent of nonHispanic, whites. 7 Unlike national statistics, lack of health
care coverage in Arizona generally increases as age
increases with 20 percent of adults over the age of 55
without health care coverage.7

Diabetes alone accounts for 10 percent of the United
States health care expenditure. A national study conducted
by the American Diabetes Association and endorsed by the
National Institutes of Health and the Centers for Disease
Control and Prevention (CDC) estimated the direct and
indirect costs attributable to diabetes in 2007 were $174
billion (Table 3), which is a 32 percent increase from
2002. Per capita medical expenditures in 2007 were
estimated to be $11,744 for people with diabetes.
Adjusted for age, sex, and race/ethnicity, medical
expenditures for people with diabetes are approximately
2.4 times more than those for people without diabetes.9

Table 3: Cost of Diabetes in the United States9

Type of Cost

Amount in billions

Direct

$116

Indirect

$58

TOTAL

$174

Diabetes also poses a large burden on the economy in Arizona. In 2005, there was nearly $3 billion in charges for
inpatient hospital stays for diabetes-related conditions, approximately 6 times higher than the amount in 1994. This
estimate does not include charges in federal facilities, such as Indian Health Service facilities.

Figure 2. Charges in Arizona for inpatient hospitalizations for diabetes-related diagnoses (non-federal facilities), 19942005

Source: Hospital Discharge Database, Bureau of Public Health Statistics, ADHS, 1994-2005

Arizona Diabetes Strategic Plan, 2008 - 2013

6

Deaths among persons with Diabetes10

Complications of Diabetes

According to the CDC, diabetes was the seventh leading
cause of death in the nation, contributing three percent of
all deaths or 72,507 deaths in 2006.11 In 2005, diabetes
was the eighth leading cause of death among Arizona
residents directly attributing to 1,196 deaths. Nationwide,
diabetes is believed to be underreported on death
certificates because persons with diabetes most often die
from cardiovascular disease or renal disease and not from
causes unique to diabetes, such as ketoacidosis or
hypoglycemia.1 Studies have found that only about 35
percent to 40 percent of decedents with diabetes had it
listed anywhere on the death certificate in only 10 to 15
percent had it listed as the underlying cause of death.
Overall, the risk for death among people with diabetes is
about twice that of people without diabetes of similar age.1
In Arizona 1,740 deaths had diabetes assigned as a
contributing factor making the diabetes-related mortality
rate (49/100,000) or 2.4 times greater than the rate for
diabetes as underlying cause (20/100,000).

Heart disease and stroke.1 Heart disease is the leading
cause of death among persons with diabetes, accounting
for about 68 percent of deaths in people with diabetes.
Heart disease death rates are two to four times higher
among adults with diabetes as compared to those without
diabetes. The risk for stroke is two to four times higher
among people with diabetes. In Arizona about 25 percent
of the adult population that had heart disease, angina
and/or stroke also had diabetes (2006).
High blood pressure.1 About 75 percent of adults with
diabetes have blood pressure greater than or equal to
130/80 mm Hg or use prescription medications for
hypertension. In Arizona 22.3 percent of the 2005 adult
population self-reported they had high blood pressure.
Blindness.1 Diabetes is the leading cause of new cases of
blindness among adults aged 20 to 74 years. Nationally,
diabetic retinopathy causes 12,000 to 24,000 new cases
of blindness each year. According to the National Eye
Institute (2004) approximately 40.3 percent of the people
aged 40 years and older with diabetes had diabetic
retinopathy. 15

The 2005 diabetes mortality rate for Arizona was 20 per
100,000. Mortality rates for each race/ethnicity were
applied to the 2005 population.

Kidney disease. Diabetes is the leading cause of kidney
failure, accounting for 44 percent of new cases in 2005.1
In 2006, 2,071 Arizonans were newly diagnosed with
chronic end stage renal disease (ESRD). Of those new
cases, 51 percent, or 1,055 Arizonans, had a primary
diagnosis of diabetes. An additional 3,508 Arizonans with
diabetes were receiving dialysis and 709 dialysis deaths
occurred as a result of diabetes in 2006.16

Diabetes mortality rates for racial/ethnic groups compared
to White, non-Hispanics:
 American Indians were 4.5 times higher,
 African Americans were 3.6 times higher,
 Hispanics were 3 times higher.

Diabetes in Persons
Less than 18 years of age

Nervous system disease. 1 About 60 to 70 percent of
people with diabetes have mild to severe forms of nervous
system damage. The results of such damage include
impaired sensation or pain in the feet or hands, slowed
digestion of food in the stomach, carpal tunnel syndrome,
and other nerve problems. Almost 30 percent of people
with diabetes aged 40 years or older have impaired
sensation in the feet (i.e., at least one area that lacks
feeling). Severe forms of diabetic nerve disease are a
major contributing cause of lower-extremity amputations.

Type 1 diabetes, an autoimmune disorder that destroys
insulin-producing pancreatic cells, is the primary form of
diabetes in childhood. It is the second most prevalent
chronic disease of childhood after asthma. Nationally, an
estimated one in every 400 to 500 children and
adolescents has type 1 diabetes.12 Preliminary reports from
the Search for Diabetes in Youth Study suggests that nonHispanic whites have the highest rate for Type 1
Diabetes.13 This study reported that type 2 diabetes,
although relatively rare, seems to be diagnosed more
frequently in adolescent minority populations. More than
five percent of Arizona high school students reported being
informed by a doctor or a nurse that they had diabetes
(5.16 percent).14

Arizona Diabetes Strategic Plan, 2008 - 2013

7

Complications of pregnancy.1 Poorly controlled diabetes
before conception and during the first trimester of
pregnancy can cause major birth defects in 5 to 10
percent of pregnancies and spontaneous abortions in 15
to 20 percent of pregnancies. Poorly controlled diabetes
during the second and third trimesters of pregnancy can
result in excessively large babies, posing a risk to both
mother and child.

Amputations.1 More than 60 percent of nontraumatic
lower-limb amputations in the United States occur in
people with diabetes. The rate of amputation for people
with diabetes is 10 times higher than for people without
diabetes. According to the Arizona hospital discharge
data, 4,015 lower extremity amputations occurred in
persons with diabetes from 2004-2006, averaging 1,338
cases per year. This is an increase of 137 cases compared
to 2000, where 1,201 lower extremity amputations
occurred in persons with diabetes.

Other Complications.1 Uncontrolled diabetes often leads
to biochemical imbalances that can cause acute lifethreatening events, such as diabetic ketoacidosis and
hyperosmolar (nonketotic) coma. People with diabetes are
more susceptible to many other illnesses and, once they
acquire these illnesses, often have worse prognoses. For
example, they are more likely to die with pneumonia or
influenza than people who do not have diabetes.
According to the Arizona BRFSS data, one-third of
Arizonans over the age of 65 years did not receive flu or
pneumonia shots in 2006.

Dental Disease.1 Periodontal (gum) disease is more
common in people with diabetes. Among young adults,
those with diabetes have about twice the risk of those
without diabetes. Almost one-third of people with diabetes
have severe periodontal diseases with loss of attachment
of the gums to the teeth measuring 5 millimeters or more.

Arizona Diabetes Strategic Plan, 2008 - 2013

8

DEVELOPMENT OF THE STRATEGIC PLAN
Background
The strategic planning process consisted of three steps
which are further outlined in "methods" below. In step 1,
two logic maps, each depicting the relationships between a
problem of interest and its roots causes, were created.
"Persons with diabetes in Arizona do not receive
recommended care and treatment" and "There is a high
incidence of diabetes/probable high incidence of
prediabetes in Arizona" were the problems that were
explored. Experts in diabetes were interviewed to identify
root causes of these problems. The root causes were
prioritized in step 2. In step 3, members of the Arizona
Diabetes Leadership Council developed strategies to
address the prioritized root causes. Strategy development
was divided among three sub-groups that focused on (1)
primary prevention, (2) improved care and treatment with
strategies focused on the patient, and (3) improved care
and treatment with strategies focused on the provider. A
fourth priority area, public policy, was added to strengthen
activities the ADC began in 2007.

The Bureau of Chronic Disease Prevention and Control
(BCDPC) is located within the Arizona Department of
Health Services (ADHS) Division of Public Health Services.
The Arizona Diabetes Program is one of many programs
housed in the BCDPC. Established in 1994 by a
cooperative agreement with the Centers for Disease
Control and Prevention (CDC), the diabetes program aims
to "reduce the incidence and prevalence of diabetes and
the disabling conditions associated with diabetes such as:
blindness, amputations and kidney disease, as well as the
personal, social and economic consequences of diabetes,
ultimately improving the quality of life for individuals and
families living with diabetes in Arizona." The Arizona
Diabetes Program work focuses on health systems
infrastructure, community interventions, disease
management, wellness, health disparities, and health
communications. The Arizona Diabetes Program achieves
many of its projects with support from partnerships and
through the Arizona Diabetes Coalition (ADC), a 300
member organization with by-laws and managed by the
Arizona Diabetes Program.
The purpose of the ADC is to reduce the burden of
diabetes on individuals, families, communities, the health
care system, and the State. This is done by increasing
awareness of diabetes, advocating for and promoting
policies and programs that improve access to care,
treatment, and outcomes for people with diabetes and
those at risk for developing diabetes. The ADC has three
committees: advocacy, education, and surveillance. The
education committee has four subcommittees: 1) provider,
2) patient, 3) hospital, and 4) public health education.
The Arizona Diabetes Leadership Council provides
direction for the activities of the ADC. Both the Arizona
Diabetes Leadership Council and ADC meet quarterly
each year.
In January 2007, Arizona Diabetes Program staff
contracted for strategic planning services with a planning
and evaluation team under the direction of Ralph Renger,
PhD at the University of Arizona Mel and Enid Zuckerman
College of Public Health. The scope of the contract was to
engage Arizona Diabetes Program staff, Arizona Diabetes
Leadership Council, and ADC members, and other
stakeholders in a strategic planning process that would
result in the development of a 5-year strategic plan, the
Arizona Diabetes Strategic Plan, 2008-2013. This plan is
to drive the activities of the ADC and of Arizona Diabetes
Program as an important partner in the ADC.
Arizona Diabetes Strategic Plan, 2008 - 2013

9

Methods
The Leadership Council actively participated in all steps of
the process. The Chair of the Council updated ADC
members at the 2007-2008 Coalition meetings. The ADC
members were requested to provide input and feedback
during all steps of the process.

Below is a description of steps used to develop the
strategic plan. The end results of this process are the
strategies listed in the next chapter, Arizona Diabetes
Strategic Plan.

Table 1: Steps in the development of the Arizona Diabetes Strategic Plan

Step

Description of Step

Responsible Party

Step 1

Construct a map of underlying
conditions identified in expert interviews

Planning and evaluation team and
experts

Step 2

Systematically prioritize underlying
conditions based on prioritization
criteria

Planning and evaluation team, Arizona
Diabetes Leadership Council, and
Arizona Diabetes Program staff

Step 3

Identify strategies that address the
prioritized conditions

Arizona Diabetes Leadership Council
and Coalition and Arizona Diabetes
Program staff (with guidance from
planning and evaluation team)

Arizona Diabetes Strategic Plan, 2008 - 2013

10

Step 1 is critical to gaining a contextual understanding of
the problem and its underlying conditions so that
ultimately, strategies can be targeted to root causes of the
problem. To arrive at this understanding, interviews are
conducted with "experts" in the problem area. For our
purposes, experts are defined as persons representing the

various stakeholder groups in the intended program.
During each interview, a facilitator guides the expert
through the process of developing a map that depicts the
relationships between the problem and its underlying
conditions.

Long Term Objectives
The CDC's Division of Diabetes Translation (DDT) administers the state-based Diabetes Prevention and Control
Programs (DPCP), of which the Arizona Diabetes Program is one. Therefore, the program is mandated to develop
objectives that mirror the DDT National Objectives. The following are the DDT National Objectives:
1. Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the
recommended foot exams.
2. Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the
recommended eye exams.
3. Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the
recommended influenza and pneumococcal vaccines.
4. Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the
recommended A1C tests.
5. Demonstrate success in reducing health disparities for high risk populations with respect to diabetes prevention and
control
6. Demonstrate success in establishing linkages for the promotion of wellness, physical activity, weight and blood
pressure control, and smoking cessation for persons with diabetes.
We have included an additional objective (Objective 7) related to primary prevention.
7. Demonstrate success in reducing the number of people who are diagnosed with pre-diabetes and diabetes.

Experts were nominated by Leadership Council and ADC
members. The Program Manager provided guidance on
which 16 persons, from a larger pool of nominees, should
be interviewed. Two of the recommended experts were
unavailable despite several attempts to contact them. An

additional expert was added based on a recommendation
from the Leadership Chair. In the end, those interviewed
(n=15) included health educators (n=5), community
advocates (n=4), health care providers (n=3), health
system experts (n=2), and a diabetes patient (n=1).

Figure 1. Problem statement for Step 1

High incidence of
diabetes/probable high
incidence of prediabetes in
Arizona

High incidence of diabetesrelated conditions in
Arizona

Persons with diabetes in
Arizona do not receive
recommended care and
treatment

Arizona Diabetes Strategic Plan, 2008 - 2013

11

Step 3 involves identification and development of
strategies that address the conditions prioritized in Step 2.
For each proposed strategy, the group of decision-makers
(in this case, Leadership Council members and diabetes
program staff) must explain how it links to one or more
prioritized conditions. In this way, the group stays focused
on addressing the conditions that were identified (1) in
Step 1 to be root causes of the problem, and (2) in Step 2
to be priorities for the group.

Each interview began with a statement of the problem.
The facilitator asked the expert why the problem exists and
noted the expert's first response on the map in relation to
the problem statement. The facilitator then turned to this
response and asked why it exists or occurs. Again, the
expert's response was noted on the map. The facilitator
continued to ask "Why?" for each response until she
reached a clear conclusion to the stream of logic (e.g., she
reached an issue that is unchangeable given available
time and resources). At that point, the facilitator returned
to the problem statement and again asked, "Why?" The
process continued until the expert felt that she had nothing
more to add to the map. The interview concluded with the
facilitator asking the expert, "In your opinion, which of the
issues you mentioned contributes most significantly to the
problem?" and "What strategies might address this issue?"

For each strategy proposed, the group was required to
provide the following information:







Step 2 involves the systematic prioritization of the
underlying conditions identified in Step 1. A facilitator
leads a group of decision-makers (in this case, Leadership
Council members and diabetes program staff) to apply
prioritization criteria to each underlying condition in a
stepwise manner. Conditions that do not meet a given
criterion are eliminated and not considered for the next
criterion. The resulting list is made up of underlying
conditions that meet all of the prioritization criteria. The
group can then engage in Step 3 of the process.




When they were sufficiently familiar with the strategy
development process, the group divided into three subgroups, focusing on (1) primary prevention, and improving
care and treatment through (2) strategies focused on
patients and (3) strategies focused on providers. These
groups met independently to brainstorm strategies and
compile the information listed above for submission to the
planning and evaluation team. Upon receipt of the
information, the team was able to write appropriate short
term, intermediate, and long term outcomes for each of
the strategies.

The Program Manager was consulted for assistance in
developing appropriate prioritization criteria based on
program conditions and constraints. The following are the
three criteria that were developed:




Within the mission of the Arizona Diabetes Program
Changeable within five years
Changeable with a budget of $1 million per year

Arizona Diabetes Strategic Plan, 2008 - 2013

The prioritized condition(s) that the strategy addresses
A description of the strategy
The rationale linking the strategy to the condition
The key audience
The potential partners, if any
An explanation of how the strategy addresses health
disparities, if it does
The data that would be needed to effectively plan the
strategy, if any
An explanation of how the strategy links to the DDT
National Objectives, if it does

12

ARIZONA DIABETES STRATEGIC PLAN 2008-2
2013
Once a project is adopted by a committee or partner, an
implementation plan with timelines, people/organizations
responsible, tasks, and deadlines will be developed to
monitor progress. Work began on this process at the
October 26, 2007 ADC meeting and continued at the
January 18, 2008 ADC meeting. In some cases, strategies
have action steps outlined in the tables.

The Arizona Diabetes Strategic plan addresses strategies to
improve the lives of people at risk for or living with
diabetes in Arizona over the next five years. The plan will
be reviewed by the Arizona Diabetes Leadership Council
and Arizona Diabetes Coalition (ADC) each year and is
flexible to change or add strategies as opportunities for
new programs or partnerships arise. The Arizona
Legislature has appropriated funds to the Arizona Diabetes
Program for diabetes and this plan will help guide the use
of these funds.

This strategic plan is broad in nature and is intended to
guide program and partnership activities. In order to
evaluate its impact, implementation plans will also address
evaluation indicators. Each objective will be reviewed to
ensure that it is a SMART (Specific, Measurable, Attainable,
Realistic and Time-sensitive) objective and is targeted
towards disparate groups most impacted by diabetes.

Strategies outlined in this plan focus on three goals:




Reduce the prevalence of diabetes;
Reduce the disabling conditions associated with
diabetes; and
Reduce the personal social and economic
consequences of diabetes.

The Arizona Diabetes Program will continue to lead the
effort to produce and disseminate Arizona surveillance
reports. Some of the long term objectives can be
measured by indicators in these reports. The following
reports are prepared by State epidemiologists with input
and guidance from the ADC Surveillance Committee and
partners of the Arizona Diabetes Coalition:

Strategies are listed in one of four priority areas:





Priority area 1-Primary prevention of type 2 diabetes;
Priority area 2-Quality care and treatment with
strategies focused on people with diabetes;
Priority area 3-Quality care and treatment with
strategies focused on health care providers; and
Priority area 4-Public policy.

Indicators Report. The indicators report is prepared
annually based on a list of selected measurable indicators
of diabetes and its complications to measure progress of
diabetes control efforts by various agencies and healthcare
systems throughout Arizona. These measurable indicators
have been selected by partners that serve on the ADC
Surveillance Committee based on quality and availability
of the data of those indicators. Indicators focus on
precursor conditions, primary, secondary, and tertiary
prevention, and mortality.

Implementation and Evaluation
For each priority area, key strategies with corresponding
short term, intermediate, and long term objectives are
outlined in tables. To facilitate implementation, each
strategy also has the following information provided:
target audience, stakeholders critical to the success of the
strategy, ADC committee, subcommittee, or ADC partner
assigned as the lead group to implement the strategy, and
ADHS program partners.

Diabetes in Arizona Status Report. This comprehensive
report is prepared every 3 years and examines the burden
of diabetes and its complications in Arizona. Its purpose is
to estimate the impact of prevalence, costs, and
complications of people with diabetes. The report notes
high risk populations and characteristics of people with
diabetes.

The committees of the ADC are Advocacy, Education, and
Surveillance. The Education Committee has four
subcommittees: 1) public health; 2) hospital; 3) patient;
and 4) provider.

Arizona Diabetes Strategic Plan, 2008 - 2013

13

Health Disparities
Diabetes affects some populations in Arizona more that
others. Specifically, type 2 diabetes affects African
Americans, Hispanics/Latinos, Native Americans, people
over the age of 45, overweight and physically inactive
people, women with a history of gestational diabetes, and
poor, less educated people. These populations will be a
high priority for this strategic plan.

A health disparity is defined as
"A population is a health disparity population if there is
a significant disparity in the overall rate of disease
incidence, prevalence, morbidity, mortality or survival
rates in the population as compared to the health status
of the general population."

We considered health disparities throughout the planning
process and drafting of the strategies. We specifically
asked, "Does this strategy address health disparities? And
If yes, how?" Implementation plans will further address
target audiences for each activity.

Minority Health and Health Disparities Research and
Education Act United States Public Law 106-525 (2000),
p. 2498

Arizona Diabetes Strategic Plan, 2008 - 2013

14

Priority Area 1: Primary prevention of type
2 diabetes

Long-tterm Objectives
Increase healthy eating of Arizonans
Increase physical activity of Arizonans

Primary prevention is the prevention of type 2 diabetes
(type 1 diabetes is not preventable and not addressed in
this section). Strategies focus on modifiable risk factorsoverweight, obesity, and a sedentary lifestyle-for
developing type 2 diabetes. Results from the Diabetes
Prevention Program, a large clinical trial funded by the
National Institutes of Health, showed the risk of developing
type 2 diabetes for people with pre-diabetes or impaired
glucose tolerance can be reduced by 57 percent through
intensive counseling on diet, exercise, and behavior
modification.17

Strategies
These strategies are further outlined in the tables below.
1. Primary Prevention Partnerships-Partner with other
organizations to support current and new programs
that educate and raise awareness about healthy
lifestyles and diabetes.
2. Healthy School Environments-Advocate for policies and
programs that support a healthful school eating and
physical activity environment.
3. Worksite Wellness-Promote and support the
implementation of worksite wellness programs.

PRIORITY AREA 1: PRIMARY PREVENTION
Goal 1: Reduce the Prevalence of Diabetes
Strategy Focus: Primary Prevention Partnerships

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)

Long-tterm Objectives (5 Years)

 By June 30, 2009, 5 collaborations between the Arizona
Diabetes Coalition and worksite, school or community
organizations will be established
 By June 30, 2009, identify 2 collaborative projects and
begin work to implement in worksites, schools, or
communities
 Implement sustained lifestyle interventions to increase
healthy eating and physical activity through the
established partnerships
 Increase healthy eating of students, employees, or
community members in participating intervention
 Increase physical activity of students, employees, or
community members in participating intervention
Partner with other organizations to support current and new
programs that educate and raise awareness about healthy
lifestyles and diabetes in school, worksite, and community
environments

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

For example:
- American Diabetes Association has educational materials
for schools
- American Heart Association advocates for physical
education in schools
- Nutrition and Physical Activity Self Assessment for Child
Care (NAP SACC): NAP SACC is aimed at improving the
nutrition and physical activity environment, policies and
practices through self-assessment, action planning,
training and targeted technical assistance.
- Arizona Nutrition Network conducts three campaigns per
year for food stamp eligible people
15

Potential Target audience

Preschool children and childcare providers, school-age
children, Food stamp eligible people, Employees
High risk populations (African Americans, Native,
Americans, Hispanics/Latinos, older people, women with
history of gestational diabetes, people with a family history
of diabetes, people who do not engage in physical activity,
overweight or obese people)

Stakeholders critical to success

American Diabetes Association, American Heart Association,
Juvenile Diabetes Research Foundation, Health Services
Advisory Group, Arizona Nutrition and Physical Activity
Alliance, State universities and community colleges in
Arizona, Midwestern University, Arizona Nutrition Network

ADC Committee(s) Responsible

Advocacy and Education

ADHS Program Partners

Arizona Diabetes Program, Nutrition, Physical Activity and
Obesity Program, Heart Disease and Stroke Program, and
Steps to a Healthier Arizona Initiative

PRIORITY AREA 1: PRIMARY PREVENTION
Goal 1: Reduce the Prevalence of Diabetes
Strategy Focus: Healthy School Environments

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)
Long-tterm Objectives (5 Years)

Strategy

 By June 30, 2009, establish a baseline measure for
number of schools that have physical education classes
 By June 30, 2009, 5 diabetes stakeholders will
participate in activities to develop, advocate for, or
implement school health policies
 Increase the number of students who report an increased
access to physical activity
 Increase healthy eating of students
 Increase physical activity of student
Use advocacy committee for awareness and support of
policies that support a healthful school eating and physical
activity environment
Partner with the Arizona Department of Education to support
their policies/program relating to healthy schools

Target audience

Legislatures, School districts, State school superintendent,
local school boards

Stakeholders critical to success

American Diabetes Association, American Heart Association,
Arizona Action for Healthy Kids, Arizona Public Health
Association, Arizona Nutrition and Physical Activity Alliance,
Arizona Department of Education, physical activity and
nutrition advocacy groups, State universities and community
colleges in Arizona

ADC Committee(s) Responsible

Advocacy

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program, and Nutrition, Physical Activity
and Obesity Program
16

PRIORITY AREA 1: PRIMARY PREVENTION
Goal 1: Reduce the Prevalence of Diabetes
Strategy Focus: Worksite Wellness

Short-tterm Objectives (1 Year)

 By June 30, 2009, recruit 60 additional organizations to
utilize the Healthy Arizona Worksites Online Assessment
and Resource Guide for developing employee wellness
programs and policies
 By June 30, 2009, establish 2 new worksite wellness
programs with Arizona employers and 4 worksites that
expand or implement new worksite policies

Intermediate Objectives (3 Years)

 Increase number of employers who have physical activity
opportunities or access to physical activity for employees
 Increase the number of workplaces that offer healthy
foods

Long-tterm Objectives (5 Years)

Strategy

 Increase healthy eating of employees
 Increase physical activity of employees
Promote and support worksite wellness programs
Action Steps:
- Assist in development of a promotion plan for the launch
of the Healthy Arizona Worksite Online Assessment and
Resource Guide to Arizona employers
- Provide feedback to refine and update the Healthy
Arizona Worksite Website; add a page that states the
business case for educating and providing support for
employees, including increased retention and productivity
- Develop a speakers bureau for people who can present
on worksite wellness
- Identify best practices of Arizona worksites and promote
access to these best practices
- Prepare a list of diabetes prevention resources and
programs for worksites to integrate into worksite wellness
programs
Support the implementation of worksite wellness programs
Action Steps:
- Advocate at the State Health Department Services level to
hire a worksite wellness coordinator to provide technical
assistance for implementation of worksite wellness
programs
- Utilize interns who can assist with worksite wellness
technical assistance
- Provide grants to employers for worksite wellness
programs that provide increased physical activity
opportunities and changes in worksites to encourage
healthy eating
- Assist in the adoption and implementation of a diabetes
worksite education program at one Arizona worksite

Arizona Diabetes Strategic Plan, 2008 - 2013

17

Target audience

Arizona employers with special emphasis on small and
midsize businesses

Stakeholders critical to success

Community involvement from: Midwestern University, State
universities and community colleges in Arizona, Arizona
Human Resources Association, Inter Tribal Council of
Arizona, Inc., American Diabetes Association, Wellness
Council of Arizona, Health Plans, American Heart
Association, Arizona Small Business Association, Arizona
Chambers of Commerce, Health Services Advisory Group,
Governor's Council on Health, Physical Fitness, and Sports

ADC Committee(s) Responsible

Education, Public Health

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Nutrition, Physical Activity and Obesity Program, Arizona
Diabetes Program, Steps to a Healthier Arizona Initiative,
and Heart Disease and Stroke Program

18

Priority Area 2: Quality care and
treatment with strategies focused on
people with diabetes

Long-tterm Objectives
Increase the number of persons with diabetes who receive
the recommended care and treatment
Strategies
These strategies are further outlined in the tables below.

People with diabetes live with this disease 24 hours a day,
7 days a week. They can be one of the most important
people on their healthcare team by learning about
diabetes, monitoring their blood glucose, and learning
good self-management skills. The strategies below
empower people with diabetes by: 1) learning about selfcare standards; 2) having an increased awareness about
the seriousness of diabetes and steps to take to manage
this disease; and 3) providing a directory with local
resources on where they can access diabetes selfmanagement training, regardless of insurance level.

1. Standards of Care-Develop, adopt, and promote
minimum standards for diabetes care in Arizona.
2. Health Communications Campaign-Implement a health
communications campaign about proper care and
treatment.
3. Resource Directory-Review, revise, and disseminate the
Arizona Diabetes Resource Directory.

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON PEOPLE WITH DIABETES
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Standards of Care
Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)

Long-tterm Objectives (5 Years)
Strategy

Potential Target audience

 By June 30, 2009, the ADC will develop and adopt
minimum standards for diabetes care in Arizona
 Deliver DSMT to 400 underserved diabetes patient
 Increase the number of patients who demonstrate proper
self-management.
 Increase the number of patients who seek out proper
care and treatment
 Increase the number of persons with diabetes who
receive the recommended care and treatment
Develop, adopt, and promote self-care standards for DSMT
and clinical standards of care
People in Arizona with diabetes
Arizonan Providers, health educators at health facilities,
community health workers/promotores

Stakeholders critical to success

American Diabetes Association, Community health centers,
Arizona Association of Community Health Centers,
pharmaceutical companies, Cooperative Extension, County
Health Departments, Health Services Advisory Group,
Arizona Health Care Cost Containment System (AHCCCS)

ADC Committee(s) Responsible

Education, Provider with support from Patient subcommittee

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program

19

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON PEOPLE WITH DIABETES
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Health Communications Campaign

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)
Long-tterm Objectives (5 Years)

Strategy

Potential Target audience

 By June 30, 2009, implement a diabetes health
awareness campaign about diabetes and its
complications
 By June 30, 2009, increase the number of people who
demonstrate increased awareness of the complications of
diabetes and how to avoid them
 By June 30, 2009, increase number of people who
demonstrate increased knowledge about diabetes selfmanagement
 Increase the number patients who seek out proper care
and treatment
 Increase the number of persons with diabetes who
receive the recommended care and treatment
Partner and provide input on the implementation of a health
communications awareness campaign about controlling
your diabetes
People with diabetes in Arizona

Stakeholders critical to success

National Diabetes Education Program, American Diabetes
Association, American Heart Association, Community Health
Centers, County Health Departments, Pharmaceutical
companies, Health Services Advisory Group

ADC Committee(s) Responsible

Education, Public Health

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program
Chronic Disease Social Marketing Team

20

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON PEOPLE WITH DIABETES
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Resource Directory
Short-tterm Objectives (1 Year)

 By June 30, 2009, revise the Arizona Resource Directory
 By June 30, 2009, distribute the Arizona Resource
Directory to diabetes primary care providers in Arizona

Intermediate Objectives (3 Years)

 Increase the number of people who receive diabetes selfmanagement training
 Increase the number of people who report that they are
less overwhelmed by the scope of self-management after
being exposed to diabetes self-management training
 Increase the number of patients who demonstrate proper
disease self-management
 Increase the number of patients who receive the proper
care and treatment

Long-tterm Objectives (5 Years)

 Increase the number of persons with diabetes who
receive the recommended care and treatment

Strategy

Review, revise, and disseminate "Arizona Diabetes Resource
Directory" for distribution at screening facilities and send to
providers with the following information:
- Where to go to get care and treatment (including lowcost options)
- Support groups in Arizona
- Diabetes education resources (e.g. DSMT programs)
Link Arizona Diabetes Resource Directory to appropriate
Websites (health disparities, AZ211, etc.)

Potential Target audience

People newly diagnosed with diabetes; low-income; Spanish
language speakers, people with diabetes who have not
received Diabetes Self-Management Training

Stakeholders critical to success

American Diabetes Association, American Heart Association,
Arizona Beneficiary Committee, Arizona Insurance Board,
AZ211, community health centers, pharmaceutical
companies, County Health Departments

ADC Committee(s) Responsible

Education, Patient with support from the Provider
subcommittee

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program

21

Priority Area 3: Quality of care and
treatment with strategies focused on
health care providers

Long-tterm Objectives
Increase the number of persons with diabetes who receive
the recommended care and treatment
Strategies
These strategies are further outlined in the tables below.

The Arizona Diabetes Leadership Council wants to share
its expertise and knowledge about delivering quality
diabetes services in Arizona. To do this requires
coordination and partnerships with other organizations,
mainly health plans and providers in the State and the use
of the Chronic Care Model, an evidence-based approach
that addresses community resources and policies and the
health system. In this model, four areas within the health
system need to be addressed: self-management support,
delivery system design, decision support, and clinical
information systems. Use of the model leads to informed
engaged patients working and interacting with a prepared
and proactive practice team. For more information about
this model go to www.improvingchroniccare.org. This goal
also addresses the need for both professional and
paraprofessional education.

1. Care and Treatment Partnerships-Align the work of the
Arizona Diabetes Coalition with what other agencies,
organizations, and companies in Arizona are doing to
improve care of people with diabetes.
2. Chronic Care Model-Promote the Chronic Care Model.
3. Professional/paraprofessional Education-Advance
professional/paraprofessional awareness and
education.

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Care and Treatment Partnerships

Short-tterm Objectives (1 Year)

 By June 30, 2009, 10 coalition and Leadership Council
members will participate in partners' committees and
workgroups
 By June 30, 2009, Leadership Council members will
develop partnerships with primary care providers to
implement a referral process into the practice for DSMT
services for patients with diabetes

Intermediate Objectives (3 Years)

 Increase the number of persons with diabetes who
receive the recommended care and treatment

Long-tterm Objectives (5 Years)

 Increase the number of persons with diabetes who
receive the recommended care and treatment

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

Align the work of the Coalition with what other agencies,
organizations, and companies in Arizona are doing to
improve care of people with diabetes.
Action steps:
- Become subject matter experts on key committees that
work towards improving care. For example, have a
member of the Arizona Diabetes Leadership Council
serve on The Phoenix Healthcare Value Measurement
Initiative.
- Advocate for the reimbursement of DSMT services with
the various health plans. For example, obtain the billing
codes acceptable for each Arizona health plan, including
AHCCCS plans and Medicare, for the providers

22

Potential Target audience

Health care plans

Stakeholders critical to success

Arizona Health Care Cost Containment System (AHCCCS),
Phoenix Healthcare Value Measurement Initiative, American
Diabetes Association, American Heart Association, Health
Services Advisory Group

ADC Committee(s) Responsible

Arizona Diabetes Leadership Council

ADHS Program Partners

Arizona Diabetes Program

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Chronic Care Model

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)

Long-tterm Objectives (5 Years)

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

 By June 30, 2009, one Chronic Care Model training will
be offered by Coalition partner
 By June 30, 2009, 10 providers will demonstrate the use
of Chronic Care Model tools by making changes in their
practice that support the Chronic Care Model
 Increase the number of providers engaging in Chronic
Care Model Methods
 Increase the number of providers demonstrating
collaboration with other providers
 Increase the number of persons with diabetes who
receive the recommended care and treatment
Promote Chronic Care Model
Action Steps:
- Partner with other agencies, organizations, and
companies who are educating providers on the Chronic
Care Model.
- For example, work with MICA (medical malpractice
insurer) to disseminate their CME approved program
educating providers on the Chronic Care Model.
- Prepare "best practices" report that highlights health care
practices that are implementing a part of the Chronic Care
Model and show improved patient health outcomes and
wellbeing (e.g., decrease in A1c and costs, patient
satisfaction, etc.)
- Develop methods for health providers/administrators to
employ patient registries
- Train providers on the Chronic Care Model

23

Potential Target audience

Primary Care Physicians (PCPs), internists, Community
Health Center providers, and residency programs

Stakeholders critical to success

MICA, American Diabetes Association, American Heart
Association, Arizona Health Query, Health Services Advisory
Group, Juvenile Diabetes Research Foundation, National
Kidney Foundation, Arizona Kidney Foundation, Maricopa
Medical Society, Pima Medical Society, other county medical
societies, State universities and community colleges in
Arizona, University of Arizona School of Medicine (Phoenix
and Tucson) Residency Programs, Midwestern University,
Central Arizona Association of Diabetes Educators, Southern
Arizona Chapter of Diabetes Educators, Osteopathic
Medical Association, Arizona Medical Association, Arizona
Association of Family Practice, Arizona chapters of American
College of Physicians and American Academy of Pediatrics.

ADC Committee(s) Responsible

Leadership Council
Support: Education, Provider

ADHS Program Partners

Arizona Diabetes Program

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS
Goal 2: Reduce the disabling conditions associated with diabetes
Strategy Focus: Professional/Paraprofessional Awareness and Education
Short-tterm Objectives (1 Year)

 By June 30, 2009, train 60 professionals and 100
paraprofessionals on proper care and treatment of
people with diabetes and pre-diabetes

Intermediate Objectives (3 Years)

 Increase the number of providers/paraprofessionals
engaged in professional education for diabetes

Long-tterm Objectives (5 Years)

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

 Increase the number of persons with diabetes who
receive the recommended care and treatment
Advance professional awareness and education
Advance paraprofessional (promotores, community health
representatives, community health outreach workers)
awareness and education
Develop recruitment plan for training paraprofessionals to
be lay leaders for diabetes self-management programs

24

Potential Target audience

Certified diabetes educators, registered dietitians, Registered
Nurses, pharmacists, primary Care physicians, internists,
nurse practioners, physician Assistants, community health
center providers, residency programs, Promotores,
community health representatives, community health
outreach workers

Stakeholders critical to success

Arizona Health Education Center, University of
Arizona/Arizona State University Medical School, State
universities and community colleges in Arizona, Midwestern
University, Central Arizona Association of Diabetes
Educators, Southern Arizona Association of Diabetes
Educators, Health Services Advisory Group

ADC Committee(s) Responsible

Leadership Council
Support: Education, Provider

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program

25

Priority Area 4: Public policy

Long-tterm Objectives
Increase the number of persons with diabetes who receive
the recommended care and treatment

Changes in legislation may be necessary in certain cases
to effectively reduce the burden of diabetes on the State,
improve insurance coverage for people with diabetes, and
reduce the costs of complications associated with diabetes.
Working with and keeping legislators and policy makers
informed about the burden of diabetes in Arizona and
changes that can make a difference in the lives of people
with diabetes and ultimately reduce costs for the State will
be key.

Strategies
These strategies are further outlined in the tables below.
1. Diabetes Day-Enhance legislative and regulatory
advocacy at state and at local levels.
2. DSMT-Promote the impact of diabetes services,
including self-management training, to legislators and
policy makers.

PRIORITY AREA 4: PUBLIC POLICY
Goal 3: Reduce the personal social and economic consequences of diabetes
Strategy Focus: Diabetes Day

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)
Long-tterm Objectives (5 Years)

Strategy

Potential Target audience

 By June 30, 2009, one diabetes day with legislators will
be held
 By June 30, 2009, membership of Diabetes Caucus at
Arizona Legislature will be updated.
 Appropriate legislation introduced as bills
 Coalition members engaged in support of legislation
 Increase the number of persons with diabetes who
receive the recommended care and treatment
Enhance legislative and regulatory advocacy at state and at
local levels.
Action Steps:
- Develop and distribute State of the State Diabetes Fact
Sheet for legislators
- Elicit testimonials, patient stories, and case studies from
organizations, and share with policy-making
bodies/committees
- Support advocacy training
Legislators, policy makers

Stakeholders critical to success

American Diabetes Association, American Heart Association,
Central Arizona Association of Diabetes Educators, Southern
Arizona Chapter of Diabetes Educators, Health facilities in
Arizona

ADC Committee(s) Responsible

Advocacy

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

Arizona Diabetes Program

26

PRIORITY AREA 4: PUBLIC POLICY
Goal 3: Reduce the personal social and economic consequences of diabetes
Strategy Focus: DSMT

Short-tterm Objectives (1 Year)

Intermediate Objectives (3 Years)
Long-tterm Objectives (5 Years)

Strategy

Potential Target audience

 By June 30, 2009, develop fact sheet outlining evidence
of effective diabetes self-management training and
distribute to Coalition members and State legislators
 Increase reimbursement for diabetes self-management
training
 Increase the number of persons with diabetes who
receive the recommended care and treatment
Promote the impact of diabetes services, including selfmanagement training, to legislators and policy makers
Action Steps:
- Identify existing evidence for effective diabetes selfmanagement training
- Conduct and publish missing gaps in outcomes research
to prove effectiveness of DSMT
- Request town hall meetings with elected officials to
develop strategies for improving federal and state
reimbursement for diabetes self-management training
and prevention
Legislators, other policy makers

Stakeholders critical to success

American Diabetes Association, American Heart Association,
Central Arizona Assn of Diabetes Educators, Southern
Arizona Chapter of Diabetes Educators, Health facilities in
Arizona

ADC Committee(s) Responsible

Advocacy

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

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REFERENCES
1. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates
on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, 2008.
2. Dabelea D, Pettitt DJ: Intrauterine diabetic environment confers risks for type 2 diabetes mellitus and obesity in the
offspring, in addition to genetic susceptibility. J Pediatr Endocrinol Metab 2001; 14(8): 1085-91.
3. American Diabetes Association: Gestational diabetes mellitus (Position statement). Diabetes Care 2004;27(Suppl. 1):
S88-S90.
4. Pettitt DJ, Knowler WC Pettitt DJ, Knowler WC: Long-term effects of the intrauterine environment, birth weight, and
breast-feeding in Pima Indians. Diabetes Care 1998; 21 Suppl 2: B138-41.
5. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general
information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health
and Human Services, National Institute of Health, 2005.
6. Population data from US Census estimates by age and sex. Accessed at http://www.census.gov/popest/estimates.php.
April 15, 2008.
7. Centers of Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance Survey Data. Atlanta, Georgia:
US Department of Health and Human Services, Centers for Disease Control and Prevention, 2000-2006. National
estimates include all states, DC and territories.
8. Harris MI, Flegal KM, Cowie CC, Eberhartd MS, Goldstein DR, Little RR, Wiedmeyer H, Byrd-Holt DD. Prevalence of
diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. Diabetes Care. 1998;21(4):518524.
9. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care, Volume 31, Number
3, March 2008.
10. Arizona Health and Vital Statistics, 2005. Arizona Department of Health Services, Section 2B.
11. Centers for Disease Control and Prevention. National Center for Health Statistics. Death-Leading Causes, 2004.
Available at http://www.cdc.gov/nchs/fastats/lcod.htm. April 15, 2008.
12. Centers for Disease and Control and Prevention (CDC). National diabetes fact sheet: general information and
national estimates on diabetes in the Unites States, 2002. Atlanta, GA: US Department of Health and Human
Services, Centers for Disease Control and Prevention, 2003.
13. Dabelea D, Bell R, D'Agostino RB, Imperatore G, Johansen JM, Linder B et al. Incidence of Diabetes in Youth in the
United States. JAMA. 2007; 297:2716-2724.
14. Arizona Department of Health Services. Yuma County Report for the 2007 Youth Risk Behavior Survey. Steps to a
Healthier Arizona Initiative, Arizona Department of Health Services, Public Health Services Prevention, December
2007.
15. National Eye Institute, Statistics and Data, Citations and Abstracts from April 2004 Archives of Ophthalmology, The
Prevalence of Diabetic Retinopathy Among Adults in the United States. Accessed at
http://www.nei.nih.gov/eyedata/pbd3.as. April 15, 2008.
16. The End Stage Renal Disease Network #15. 2006 Annual Report. Contract Numbers: 500-03-NW15 and HHSM500-2006-NW015C with Centers for Medicaid & Medicare Services, Baltimore, MD. Accessed at
http://www.esrdnet15.org and http://www.esrdnetworks.org. April 15, 2008.
17. Diabetes Prevention Program Research Group. N Engl J Med. Reduction in the Incidence of Type 2 Diabetes with
Lifestyle Intervention or Metformin. 346:393, February 7, 2002.
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ABBREVIATIONS
A1C

Hemoglobin A1C

ACE inhibitors

Angiotensin converting enzyme inhibitors

ADC

Arizona Diabetes Coalition

ADHS

Arizona Department of Health Services

AHCCCS

Arizona Health Care Cost Containment System

ARB

Angiotensin receptor blockers

BCDPC

Bureau Chronic Disease Prevention and Control

BRFSS

Behavioral Risk Factor Surveillance Survey

CDC

Centers for Disease Control and Prevention

CME

Continuing Medical Education

DDT

Division of Diabetes Translation

DPCP

Diabetes Prevention and Control Programs

DPP

Diabetes Prevention Program

DSMT

Diabetes Self-Management Training (synonymous with Diabetes Self-Management Education or DSME)

ESRD

End stage renal disease

GDM

Gestational diabetes mellitus

HDL

High-density lipoproteins

IFG

Impaired fasting glucose

IGT

Impaired glucose tolerance

IDDM

Insulin-dependent diabetes mellitus

LDL

Low-density lipoprotein

NAP SACC

Nutrition and Physical Activity Self Assessment for Child Care

NIDDM

Non-insulin dependent diabetes mellitus

PCP

Primary Care Physicians

SMART

Specific, Measurable, Attainable, Realistic and Time-sensitive

STOP-NIDDM

Study to Prevent Non-Insulin-Dependent Diabetes Mellitus

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