Diabetes is a lifelong condition, but complications—and costs—can escalate quickly: emergency visits for high blood sugar, strokes linked to uncontrolled blood pressure, kidney failure requiring dialysis, or sudden vision loss. With 38 million U.S. adults living with diabetes and complications costing more than $400 billion each year, consistent, proactive care matters. Many of the most serious outcomes are preventable when diabetes is identified early and managed reliably.

For providers in value based care, diabetes is one of the clearest opportunities to reduce avoidable utilization while improving patient wellbeing. You do not need a complex program—just a dependable system that helps your team execute five core steps every time.‑based care, diabetes is one of the clearest opportunities to reduce avoidable utilization while improving patient well‑being. You do not need a complex program—just a dependable system that helps your team execute five core steps every time.

1) Monitor average blood sugar—and act early

Make it easier in practice

A1c testing shows a patient’s average blood sugar and helps identify risk before it becomes a crisis. Some patients may benefit from continuous glucose monitors, but the goal is the same: detect problems early and adjust the plan before complications build.

• Keep A1c tests (or CGM reviews) on a routine schedule.
• Use a straightforward action plan for high results—medication review, nutrition support, and a clear follow‑up date.
• Standardize reporting so the team can respond consistently.

2) Treat blood pressure control as essential diabetes care

High blood pressure is a major driver of strokes, heart attacks, and kidney damage in people with diabetes. Many programs use <140/90 as a basic control target. Reliable workflows—not just clinical knowledge—prevent high readings from going unaddressed.

Make it easier in practice

• Repeat a high blood pressure reading before the visit ends and document the final result.
• Support home blood‑pressure monitoring and quick follow‑ups by phone, text, or short in‑person visits.
• Use a shared playbook across the care team to ensure consistent treatment.

3) Ensure retinal eye exams get completed

Retinal exams catch eye disease early, long before vision loss. When vision declines, patients face safety risks, medication challenges, and reduced independence. Referrals alone are not enough —completed screenings are what prevent future high-cost complications.

Make it easier in practice

• Track completed exams, not just referrals.
• Schedule the exam before the patient leaves when possible.
• Follow up on missed appointments through text, calls, or community health worker outreach.

4) Perform annual kidney checks with both required tests

Kidney disease is one of the costliest diabetes complications, and early damage has no symptoms.

A complete annual check requires two tests:

• A blood test for kidney filtration
• A urine test for early kidney damage

Missing these tests often leads to late detection, fewer treatment options, and higher costs.

Make it easier in practice

• Order both labs together using a standard annual diabetes panel.
• Catch missing labs during pre‑visit planning.
• Make a clear plan for abnormal results, including medication adjustments, repeat testing, and referral timing.

5) Protect the heart with statin therapy—and support adherence

Heart disease is one of the biggest risks and cost drivers in diabetes. Statins reduce cardiovascular events for many adults, particularly those ages 40–75. Prescribing is only the first step—ongoing support prevents patients from quietly stopping the medication.

Barriers like side effects, cost, or mistrust are common but solvable.

Make it easier in practice

• Ask about side effects early and often.
• Address cost and pharmacy access directly.
• Use nurse or pharmacist touchpoints to support adherence.

Dedicated to Better means fewer gaps—and fewer crises

Better diabetes outcomes come from dependable systems, not heroic effort. Clinics that reduce avoidable costs typically:

• Maintain a simple diabetes registry to track A1c, blood pressure, eye exams, kidney tests, and medication needs.
• Use pre‑visit planning to address gaps before the appointment begins.
• Share responsibility across MAs, nurses, care coordinators, and community health workers.

This is what “Dedicated to Better” looks like in action: better outcomes, reduced avoidable spending, and a more sustainable workload for care teams—especially in under‑resourced communities where chronic disease has been made harder than it should be.