The UAB Center for Clinical and Translational Science (CCTS) has awarded Seung-Yup (Joshua) Lee, assistant professor in the UAB Department of Health Services Administration, a 2024 CCTS Pilot Award.
Lee’s project, titled “Empirically-Grounded Referral Optimization for Effective Diabetes Care Coordination and Glycemic Management,” looks to create an algorithm-based mechanism that would classify patients into distinct groups based on their needs and risks.
Ultimately, he hopes this tool will help fill gaps in the diabetes care continuum. He says there are countless people with diabetes who fall between primary care providers (PCPs) who provide daily care and endocrinology services who provide specialty care.
“We need intermediate clinics for people with diabetes who are caught in the middle with nowhere to go,” said Lee. “But we first need to be able to correctly identify the true intermediate target population. Diabetes care involves multiple health determinants, and physicians benefit from structured guidance. That’s why we’re developing a standardized, evidence-based referral protocol to support physicians – and that is what we are working to build, test and deliver.”
Lee and his team, who began this work after being awarded the School of Health Professions Interdisciplinary Collaborative Grant in 2023, are working with a broader network across UAB. This group—spanning from PCPs, endocrinologists, and health services researchers—reflects the UAB Health System’s commitment to improving care for patients with diabetes. Building on determinants of health identified in an earlier collaboration, Lee’s team has gathered the electronic health records for all patients with diabetes and phenotyped them to optimize referrals.
“UAB Medicine serves more than 1.5 million patients every year. They have a lot of data and widely diverse sets of data since they manage everything from the largest hospital in the state to small clinics in rural areas,” said Lee. “It is important for my team to build a clear bridge between the gap from PCPs to endocrinology services and I believe we can do great research with such strong insights all in one system.”
Following the data gathering process, Lee and his team will conduct qualitative interviews with providers. They want to make sure their algorithm makes sense in the medical field and that they have identified the right conditions to inform the referral process.
Once the referral criteria are confirmed, they will conduct further research to make sure the criteria will work based on operation practice, capacity and sustainability.
Their hope is that their work with the diabetes population will be scalable and generalizable to impact even more people in need.
“We hope that this optimized referral protocol could provide the setting for a transitional care clinic that could be scaled and generalized for any diseases,” said Lee. “It is a way to serve a patient at intermediate risk where you could potentially prevent them from escalating to high risk and eventually bring them back to low risk and the PCP care. Right now, there is no standardized mechanism to support this, and we hope our research will contribute to advancing transitional care delivery.”
