Why Diabetes?

The rate of new cases of diagnosed diabetes in the United States has begun to fall, but the numbers are still very high. More than 29 million Americans are living with diabetes, and 86 million are living with prediabetes. Individuals with type 2 diabetes are at increased risk of heart disease, stroke, hypertension, kidney disease, blindness, depression and other chronic diseases (CDC, 2016).


What We Do

RCHC’s 4-Point Evidence-Based Care (EBC) program on diabetes management includes shared clinical guidelines for management of type 2 diabetes, clinical decision support tools, sharing of best practices, and quality improvement and population health support in the form of trainings. The quality improvement (QI) leads from health centers are working together in 2018 to support patients with diabetes to live well and healthy lives through an ongoing RCHC Quality Culture Series. The Quality Culture Series focused on improving blood sugar control among patients with diabetes aims to accomplish the following:

  • Provide an opportunity for clinic members to learn together in a concentrated away-from-clinic environment;
  • Facilitate increased collaboration and transparency in sharing QI projects and methods;
  • Offer a forum for sharing information across all QI leads to allow individuals to connect when working on similar projects; and
  • Accelerate spread of culture of quality at health centers.

Guidelines and Protocols

To access the guidelines listed below, click here.

  • RCHC Diabetes Management Guideline
  • RCHC Diabetes Management Medication Titration Algorithm

For the RN Standardized Procedure:

Clinical Decision Support

RCHC Diabetes Management CDS Package 

Promising Practices

Promising Practices – Diabetes Management


RCHC Training Calendar

Who We Serve

We serve the 13 participating health centers and over 200,000 health center patients from 5 counties: Marin, Mendocino, Napa, Sonoma, and Yolo.

Health Centers: Alexander Valley Healthcare, Anderson Valley Health Center, Coastal Health Alliance, CommuniCare Health Centers, Marin City Health and Wellness, Marin Community Clinics, OLE Health, Petaluma Health Center, Ritter Center, Santa Rosa Community Health Centers, Sonoma Valley Community Health Center, West County Health Centers, and Winters Healthcare Foundation.


“This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H2QCS30258, Health Center Controlled Networks, for $1,500,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”

Project Timeline

August 1, 2016 – July 31, 2019


Outcome Measures
Diabetes – HgbA1c Control


Health Centers:

  • Alexander Valley Healthcare
  • Anderson Valley Health Center
  • Coastal Health Alliance
  • CommuniCare Health Centers
  • Marin City Health and Wellness
  • Marin Community Clinics
  • OLE Health
  • Petaluma Health Center
  • Ritter Center
  • Santa Rosa Community Health
  • Sonoma Valley Community Health Center
  • West County Health Centers
  • Winters Healthcare Foundation

Strategic Partners:

  • Health Resources and Services Administration (HRSA)


For more information, please contact Michelle Rosaschi.



Link to PHASE Program Page

Centers for Disease Control and Prevention microsite below: