March 3, 2026
Chronic diseases are the leading driver of health care costs in the U.S., accounting for about 90% of total spending. Diabetes alone costs an estimated $413 billion each year and is the most expensive chronic disease in the nation, affecting the quality of life for more than 40 million Americans.
In the OCHIN network, more than 670,000 people have diabetes. At the same time, a demographic surge of older adults entering Medicare eligibility throughout the U.S. indicates that even more people are at risk for developing the condition, as the risk for type 2 diabetes increases with age. Because value-based care programs seek to link improved health care outcomes with increased health care savings, it is increasingly important that providers in rural and lower-resourced communities have the tools and support needed to help their patients effectively manage diabetes and live healthier lives.
In partnership with OCHIN, providers in community health organizations nationwide are leading the way in integrating evidence-based interventions, technology, and whole-person care to reduce costs and improve outcomes for people with diabetes.
Improving financial sustainability and patient health through technological innovation
Value-based care is a payment model that emphasizes patient outcomes rather than the volume of services, with the goal of delivering high-quality, whole-person care. Value-based care can help improve patient outcomes, lower costs to the system, and improve financial sustainability for community health organizations.
An unmet need for providers in rural and lower-resourced communities is the challenge of providing high-quality care for people who have more complex medical needs and face barriers to care, such as unreliable access to food or transportation. One way OCHIN network providers are overcoming these challenges and helping their patients with diabetes achieve better health is by using comprehensive tools and AI-driven technology integrated into their OCHIN Epic electronic health record. These tools support care management at all stages: before the appointment, during the visit, and after the visit.
For example, providers can proactively manage diabetes outcomes using a diabetes-specific component in their OCHIN Epic Care Manager Dashboard to guide workflows, assess risk, support early intervention, and reduce the likelihood of complications such as heart or kidney disease. The generative AI-driven Outpatient Insights tool helps clinicians prepare for upcoming visits by creating concise summaries of past medical encounters, while the Synopsis report enables providers to trend the patient’s diabetes-related vitals, labs, and medication history over time.
Using a team-based care model, one rural Oregon member uses OCHIN Epic tools such as Reporting Workbench and Healthy Planet to identify people at risk for diabetes, enabling providers to proactively enroll patients in the clinic’s Diabetes Prevention Program. Another member relies on OCHIN Epic screening tools to identify nonmedical factors influencing health outcomes and connect patients experiencing food insecurity with an in-house food and vegetable voucher program.
This integrated, whole-person approach leads to better health outcomes and reduced systemwide costs—a hallmark of success in value-based care.
Consultative support and solutions expertise for diabetes care
As an integrated knowledge solutions partner, OCHIN understands that technology alone is not a one-size-fits-all solution. Measurable practice transformation that supports a transition to value-based care must be both data-driven and human-centered. Because improving diabetes outcomes depends on ensuring that both provider and patient voices are heard, OCHIN practice coaches work side by side with member clinics to help them better understand their unique patient populations, strengthen engagement strategies, implement system-level improvements, and more.
In diabetes care, this often includes examining how people, processes, and technology intersect to support patients and staff. The work aligns data, strategy, and evidence-based practices with a team-based care model while using digital health tools to help organizations achieve their goals and advance whole-person care in support of value-based care.
Practice coaches provide consultative support to health center care teams, empowering them to use population health management (PHM) digital tools to improve clinical care and operations and close care gaps that affect clinical quality measures, including diabetes.
“One of Share Ourselves’ pillars in its strategic plan is providing an exceptional experience to improve patients’ health outcomes,” said Anna Tiongco, quality and clinical systems director at Share Ourselves, an OCHIN member in California. “With the support of the practice coaches at OCHIN, we were able to conduct Kaizen (continuous improvement) events, pre-visit planning workforce development, and PDSA (plan, do, study, act) to facilitate small tests of change optimized with use of OCHIN Epic EHR integrated tools.”
Advancing our understanding of diabetes care
OCHIN research continues to advance understanding of diabetes care across the OCHIN network and nationally. Studies have examined preventive services, insurance continuity, and care quality while exploring differences in diabetes outcomes, the impact of Medicaid expansion, and the role of EHRs in improving data quality.
For example, OCHIN researchers have examined how nonclinical drivers of health influence diabetes outcomes and provided actionable evidence of the importance of screening for nonmedical health-related needs through existing OCHIN Epic tools. Another study found that while diabetes quality improvement programs focused on medication management are successful in improving outcomes, implementation is often challenging due to workflow changes and staff training needs. These barriers are key focus points for OCHIN’s consultative model, which helps reduce the burden on staff when implementing new workflows or quality improvement initiatives.
OCHIN researchers and partners are actively pursuing projects that use advanced technologies and innovative care models to improve diabetes outcomes through AI-driven care pathways, remote patient monitoring, and integrated approaches that address social and contextual barriers, enhance preventive care, and optimize treatment strategies for people living with diabetes.
Learn more
For more information about how OCHIN’s integrated knowledge solution can support providers caring for people with diabetes and other chronic conditions in an era of value-based care, visit our website or contact us.
