(P501) A Model for a Scalable Technology-Enabled Evidence-Based Diabetes Care Pathway for Older Adults

Apostle Group, LLC, Rockville, MD, a CMS Care Transformation Organization, is partnering with the Administration for Community Living to develop a statewide standardized system of care delivery for older adults with diabetes. This includes the development of partnerships between healthcare and community-based area agencies on aging (AAA) to provide access and coordinated continuity of care by use of eReferral technology via the Chesapeake Regional Information System (CRISP). This poster reviews a demonstration project enrolling 200 older adults with diabetes (> 60 years) that seeks to determine if a state-wide collaborative partnership linking healthcare and human services can develop a scalable, coordinated, continuous diabetes care pathway model to decrease cost and increase access to resources using technology to improve quality of care. The project aims to establish a diabetes pathway that provides reimbursement and integrates the referral process to diabetes education programs, Medical Nutrition Therapy (MNT), and human services in CRISP; 2) redeploys existing resources using technology to improve access to care, reduce social isolation and food insecurity; 3) develops medically tailored 4-week menu options by partnering with local partners for production and on-demand delivery.