Southwest Diabetes & Obesity Consortium

Click here to read “Diabetes in Arizona: The 2018 Burden Report”


The Arizona Diabetes Foundation is a 501 (c)(3) non-profit organization seeking to enhance pre-diabetes and diabetes awareness and to promote healthy lifestyles through innovative educational programs for at risk targeted populations and to improve the diabetic care of individuals in the State of Arizona. To achieve the greatest public health impact possible, the Arizona Diabetics Foundation has partnered with Mission of Mercy and the Valley of the Sun YMCA.

Mission of Mercy is an independent nonprofit 501 (c)(3), faith-based community organization that provides free healthcare/prescription medications to the uninsured and under-insured.

The Valley of the Sun YMCA promotes a healthy lifestyle through their Diabetes Prevention Program to assist individuals in the prevention, delay or how to live better with chronic conditions.


A 3-year collaborative program plan from 2019-22 has been designed to reach 9,000 participants. A summary of the program objectives include:

  1. Increase pre-diabetes, diabetes, and chronic kidney disease awareness specifically in at-risk populations in the State of Arizona.
  2. Host 10 outreach sites throughout the State of Arizona
  3. Conduct 3,000 screenings per year. The screening will consist of:
  • Hemoglobin A1c 
  • Blood pressure
  • BMI
  • Microalbumin
  • Tobacco use
  • Exercise Level
  1. Refer insured participants that are diabetic and/or deemed high risk to their Primary Care provider for the continuation of care and monitoring according to AACE (American Association of Clinical Endocrinologists) guidelines.
  2. Refer uninsured/under-insured participants who have diabetes and/or deemed high risk to Mission of Mercy for the continuation of care and monitoring according to AACE (American Association of Clinical Endocrinologists) guidelines.
  3. Refer all participants to the YMCA to pursue the continuation of living a healthier lifestyle.

We believe that this project will introduce our center and services to an extremely underserved population. As a result, we anticipate a rise in pre-diabetes and diabetes self-management, less high-risk participants without medical care, and improved quality of life for those participants due to the introduction to health services for the un-insured, underinsured and wellness activities.

Proposal Narrative

  1. Grant Type –Mobilize Arizona – Early Identification of Diabetes, Chronic Kidney Disease and Obesity Project
  1. Background and Problem Statement:

The Arizona Diabetes Foundation (AZDFN) was established and granted a 501©3 designation as a charity on June 27, 2007.  A Board of Directors was founded to guide the direction of the foundation. Our focus over the past 11 years has been providing innovative educational diabetes programs free to the general public and medical community.  To date we have served over 10,000 community participants in our free diabetes educational seminars and have provided over 38 free CME seminars serving over 12,000 medical providers including RN/BSNs, doctors, physician assistants, medical assistants, and nurse practitioners.  As founder, Dr. Roberto Ruiz, has a long history and interest in diabetes education and treatment.   

The mission and objectives of AZDFN is to enhance diabetes awareness through innovative education programs, promote healthy lifestyles and improve diabetic care, targeting those most at risk, minority, low-income, and un-insured populations in Arizona.   

Diabetes is one of the most destructive and fastest growing diseases in Maricopa County, the state of Arizona and the U.S.  Maricopa county and the state of Arizona has a significant number of high-risk low-income populations, many who are un-insured or under insured and Hispanic, Native American and African Americans’ who make up 43% of the state’s population are shown to have a significant increase in diabetes and lack of health care services to treat diabetes. 

Diabetes is closely linked to obesity and physical inactivity.  Over one in four Arizona adults in 2016 were obese, similar to the national average of 29% (Diabetes in AZ Burden report).  Type 2 diabetes has doubled in the last ten years in Arizona and between 2011 and 2016, adults with diabetes increased from 9.5% to 10.8%.   (AZ Department of Health Services) The burden of diabetes in Arizona is an epidemic.  It costs Arizona an estimated $6.8 billion each year.  Approximately 695,000 people have diabetes and of these an estimated 172,000 have diabetes but are unaware that they have it, which greatly increases their health risk.  Adding to those numbers are the 1,796,000 people in Arizona who have prediabetes, 37.5% of the adult population with blood glucose levels higher than normal but not yet high enough to be diagnosed with diabetes who without information and intervention will become diabetic.  The risk of developing diabetes can be reduced with a 7% reduction in weight and moderate physical activity. 

  1. Activities:

AZDFN has educated over 10,000 individuals in the past eleven years of operation in free diabetes educational seminars that have targeted individuals in low-income high-risk communities.   We have educated 10,000 medical professionals in Arizona and 2,000 in Texas/New Mexico in free CME programs, increasing provider knowledge on diabetes and diabetes management to improve patient outcomes.

AZDFN in collaboration with its partners, Valley of the Sun YMCA (VOSY) and Mission of Mercy (MOM) have designed a 3-year project plan to reach 9,000 participants through 10 outreach sites and usage of the University of Arizona mobile van to expand screening outreach to community health fairs throughout the State of Arizona.  Our program objectives will include:

  1. Increase awareness of pre-diabetes, diabetes, chronic kidney disease and the role obesity plays specifically in at-risk populations in Arizona
  2. Utilize 10 or more outreach sites to conduct 3,000 screening per year, and 9000 in three years, at MOM sites in greater Phoenix and VOSY’s located in Maricopa, Pinal, Yuma, Yavapai and Coconino counties. In addition, VOSY will expand screenings to all 16 VOSY communities at our annual Healthy Kids day on April 27th designating BCBS as the YMCA Healthy Kids day sponsor. Screening tests will include: Hemoglobin A1c, Blood Pressure, BMI-Body Mass Index, Microalbumin, Tobacco Use and Exercise Levels.
  3. Referrals will be made for all patients that are diabetic and/or deemed high risk as follows:
    1. Insured participants will be referred to their Primary Care provider for the continuation of care and monitoring according to ACCE – American Association of Clinical Endocrinologists guidelines.
    2. Refer uninsured/under-insured participants determined at high risk to MOM for diabetes education, medical care and monitoring according to ACCE – American Association of Clinical Endocrinologists guidelines.
    3. Refer all screened participants to local YMCAs to pursue a healthier lifestyle through diabetes education, exercise and wellness activities, with 3 months of grant supported individual or family membership.
  4. MOM and VOSY will recognize BCBS partnership through in-kind sponsorships, branded “give-aways” to expand community visibility and increase project awareness.
    1. The partner agencies will recognize BCBS as a sponsor, at the 2019 MOM community breakfast and at all 16 VOSY Healthy Kids days on April 27, 2019.  AZDFN will recognize BCBS as a partnering sponsor on their website and at all CME and patient education programs.
  1. Organization Infrastructure:
    1. The Arizona Diabetes Foundation dba Southwest Diabetes and Obesity Consortium will oversee the grant under the direction of the Executive Director and Principal investigator, Dr. Roberto Ruiz, MD, FACP and the Grant Program Director, Beth Salazar, MA, CAP, with assistance from Mayela Hernandez, Quality Project Coordinator.
    2. Partner organizations Mission of Mercy (MOM) under the direction of Paula Carvalho, Executive Director and Libby Corral, Sr. Vice President, Valley of the Sun YMCA (VOSY) will conduct the screenings of 3,000 individuals per year, 9000 total and record the information in eCW – (software) and make the appropriate referrals to PCP for insured individuals and MOM for underinsured, uninsured. In addition, all positive screened participants will be referred to the YMCA for exercise and wellness activities through a 3 months Y membership (one month in kind and 2 months grant supported).
    3. Evaluation of grant and analysis of screening data will be conducted by Dr. Daniel Magee, PhD, ASU Dept of Biomedical Informatics partnering for participant screening data will be documented by Physician’s Trust (eCW) through the system servers that will be managed and maintained with high integrity under the direction of Steve Rhodes, President and Information Technology supported by Travis Lass, XLCON, (HIPPA compliant servers).
    4. The Grants Program Director and the Financial Coordinator will oversee monthly financial reporting by the collaborating partners and monitor the monthly expense reports each month and provide ongoing monitoring of the budget monthly and year to date expenses. The Grants Program Director will work closely with the Quality Project Coordinator to monitor all collaborating program partners’ activities and outcomes.
    5. The Finance Coordinator will be responsible for the development and preparation of monthly, quarterly and annual financial and accounting information.  Process payroll, accounts payables and receivables, (invoices, check requests and expense reimbursements) and purchase requisitions.
    6. The Quality Project Coordinator will be responsible for coordinating and implementing patient engagement/care systems.  Monitor project performance of collaborating partners by organizing, analyzing and verifying clinical data and perform monthly audits reports.  Provide staff training in continuous quality improvement methodologies.
  1. The Executive Assistant will be responsible for providing administrative and clerical support for the project within area of responsibilities that may include telephone support, filing, typing, coordinating schedules, distributing correspondence, materials management, data entry and simple data analyses.
  1. Success Measures and Reporting:
    1. Intended outcome, both short-term and long-term
      1. Screen 3,000 participants annually, 9,000 in 3 years for obesity, diabetes, pre-diabetes, chronic kidney disease, tobacco use, and level of exercise.
      2. Refer participants to PCP or MOM for diabetes education, early intervention and treatment to improve health outcomes.
      3. Refer participants to YMCA for diabetes education, wellness activities to improve health and reduce BMI, and lower levels of obesity.
    2. Demonstrated outcomes – existing metrics
      1. Pre-diabetes can be prevented with a 7% reduction in weight, engaging in exercise and wellness activities as a 3-month YMCA member will make this outcome easier to achieve.
      2. Pre-diabetes and diabetes outcomes improve with early diagnosis and referred to medical professionals following the care and monitoring according to ACCE – American Association of Clinical Endocrinologists guidelines.
      3. Participant referrals will be made to Primary Care doctors for those insured and to MOM for uninsured for ongoing care and monitoring according to existing guidelines, ACCE – American Association of Clinical Endocrinologists guidelines.
      4. Pre-diabetes and diabetes outcomes improve when patients improve their diabetes knowledge and self-management skills.
    3. Reporting – in addition to required quarterly reporting to BCBSAZ, describe other reports and strategies you will use to communicate results.
      1. The Executive Director- Principal Investigator will monitor the collection and analysis of data with all partners in the AZDFN Early Identification and Intervention of Diabetes, Chronic Kidney Disease and Obesity Project. Refer to Addendum A for Data Analytics Protocol
      2. The Grant Program Director will track partner activities, education activities and monthly screening progress thru bi-monthly collaborator meetings and conference calls and will measure progress each month and monitor and coordinate monthly reports on screening activity to reach 3,000 annual screenings and 9,000 total screenings.
      3. The Grant Program Director will work closely with the Finance coordinator to collect and review monthly finance reports for all collaborators.
      4. The Grant Program Director will work closely with Dr. Ruiz, project staff and partners in preparation of grant reporting and budget reconciliation.



  1. The Valley of the Sun YMCA and Mission of Mercy
    1. Perform 3,000 screens annually utilizing measures listed in screening form.
    2. Input data in eClinical Works (eCW) database.
  2. Arizona Diabetes Foundation (AZDFN)
    1. Populate the data and generate report utilizing eCW database.
    2. The generated data is reviewed to provide appropriate assessment and use of applicable diagnosis code(s):
    3. Z00.00 Routine Medical Exam, Normal
    4. E11.65 Diabetes Mellitus Type 2, Uncontrolled
    5. E88.81 Dysmetabolic Syndrome
    6. R73.03 Pre-Diabetes
    7. I11.9 Hypertensive Heart Disease
    8. R80.9 Microalbuminuria
    9. E66.01 Morbid Obesity, BMI >30
    10. E66.30 Overweight, BMI 26 – 29
    11. Z72.0 Tobacco Use
    1. All participants will be mailed a letter of program participation. A copy of the letter will be sent to the insured participant’s primary care physician and underinsured/uninsured participants to Mission of Mercy for follow-up care.
    2. Each participant will receive a three month free membership to the YMCA – Diabetes Prevention Program to include diabetes education and exercise program.
    3. Monthly data management and analytics and context aware systems and predictive modeling will be conducted by Dr. Daniel Magee, ASU Biomedical Informatics.
    4. Conduct participant survey via letter and telephone call in an effort to obtain outreach program effectiveness.