Providence St. Joseph Health Announces Five-Year Program to Improve Access to Diabetes Care for Portland’s Most Vulnerable

Michael Connors
October 18, 2017

Three Portland-area clinics will extend integrated services and programs for managing diabetes

Portland, Oregon—Living with type 2 diabetes isn’t easy when you don’t have the resources to manage the disease. To help Medicaid and uninsured patients find new hope, Providence St. Joseph Health today launched the Providence Diabetes Collective Impact Initiative at three Portland-area clinics. The initiative is made possible by a $1.5 million, five-year Merck Foundation grant.

High rates of diabetes, along with hypertension and depression, are the most common chronic conditions among Oregon’s Medicaid population. For the most vulnerable in the Portland area, barriers to effectively managing their condition include lack of access to medical care, poor quality of care, employment instability, and insufficient food, transportation, housing or other resources for healthy living.

This new initiative represents a comprehensive approach that brings together high quality health services with community-based services to address many factors influencing health, such as access to nutritious foods, safe options for physical activity and housing stability. It is part of Providence St. Joseph Health’s strategy for proactively addressing the specific health and social needs in its communities through accessible and preventive care.

"The Diabetes Collective will help bridge health care provided in our clinics with our community service partners," said Rhonda Medows, M.D., Providence St. Joseph Health executive vice president of population health. “Chronic health conditions such as type 2 diabetes can be successfully managed, and we’re committed to providing underserved communities with the care and the help they need to do that. We know how important it is to use our resources and our experience working in different communities to reduce health disparities and treat conditions such as diabetes that can be prevented and effectively managed.”

The Providence Diabetes Collective Impact Initiative will bring together multiple community groups to provide health care and social service interventions at three Providence Medical Group clinics: PMG-Gateway Family MedicinePMG-Milwaukie Family Medicine and PMG-Tanasbourne Family Medicine. The goal is to make it easier for patients to access critical social services at the same time that they’re receiving expert care. These interventions include:

  • Identifying gaps in patient care using an electronic medical record and through primary care provider conversations with patients
  • Identifying people in the community with type 2 diabetes who are not receiving the care they need, and referring those patients to the pilot clinics
  • Co-locating social service agencies in the same buildings as the three clinics to make it easier for patients to receive the integrated medical and social service help they need to manage their chronic health condition
  • Equipping primary care physicians to screen for needs such as food, housing and transportation to increase referrals to the social service agency
  • Providing patient-centered care management for the highest risk patients
  • Providing multilingual, in-person education and offering support groups

“We need to look beyond the usual health care solutions to address the growing burden of diabetes, especially among vulnerable populations in the United States,” says Julie L. Gerberding, Chief Patient Officer, Merck and Chief Executive Officer, Merck Foundation. “Through Bridging the Gap, we are pleased to bring together these eight diverse organizations, and look forward to leveraging their expertise to help more people effectively manage their diabetes and improve their overall health.”

For more information, visit

About Providence St. Joseph Health

Providence St. Joseph Health is committed to improving the health of the communities it serves, especially those who are poor and vulnerable. With 50 hospitals, 829 physician clinics, senior services, supportive housing and many other health and educational services, the health system and its partners employ more than 111,000 caregivers (employees) serving communities across seven states – Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. With system offices based in Renton, Wash. and Irvine, Calif., the Providence St. Joseph Health family of organizations works together to meet the needs of its communities, both today and into the future.

About the Merck Foundation

The Merck Foundation is a U.S.-based, private charitable foundation. Established in 1957 by Merck, a leading global biopharmaceutical company, the Foundation is funded entirely by the company and is Merck’s chief source of funding support to qualified non-profit charitable organizations. Since its inception, the Merck Foundation has contributed more than $870 million to support important initiatives that address societal needs and are consistent with Merck’s overall mission of inventing for life by bringing forward medicines and vaccines for many of the world’s most challenging diseases. For more information, visit

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