Diabetes Workgroup

The Diabetes Workgroup is charged with developing a citywide diabetes strategy for Baltimore City residents. This strategy will focus on pre-diabetes screening, prevention, early intervention, and self-management techniques such as promoting healthy eating habits, physical activity, and smoking cessation. This work also involves understanding the epidemiology of diabetes, examining gaps in service delivery, identifying priorities and recommendations for action, and engaging community stakeholders to support implementation of those recommendations.

In collaboration with the two regional partnerships of Baltimore Metropolitan Diabetes Regional Partnership (University of Maryland Medical Center & Johns Hopkins Medicine) and Saint Agnes and LifeBridge Diabetes Health Collaborative (St. Agnes & LifeBridge Health), the Baltimore City LHIC hopes to establish and support new referral pathways for the screening, prevention, early intervention, and self-management education of Baltimore City residents at risk or diagnosed with pre-diabetes/diabetes. 

Baltimore Metropolitan Diabetes Regional Partnership

Healthier Together

Two world-class health systems to help Marylanders prevent and manage diabetes


University of Maryland Medical Center (UMMC) and Johns Hopkins Medicine (JHM) have collaborated to create the Baltimore Metropolitan Diabetes Regional Partnership — publicly known as Healthier2gether.

Our collaborative works with community organizations to increase the number of available city-based programs to prevent or delay Type 2 diabetes, and to increase access to community-based diabetes management programs to help people in Baltimore City and throughout Maryland who live with diabetes improve their health outcomes.

This statewide population health initiative is made possible through a grant awarded by the Maryland Health Services Cost Review Commission and is to be implemented over five years. The unified goal of Healthier2gether is to expand the CDC’s National Diabetes Prevention Program and the Diabetes Self-Management Education and Support Program and American Diabetes Association–recognized Diabetes Self-Management Education and Support programs, as well as evidence-based Centers for Medicare & Medicaid Services–reimbursed diabetes prevention and management services.

Where there is the greatest need for diabetes programs

The JHM and UMMC collaborative makes diabetes programs available where more people need help to prevent or manage diabetes, focusing on:

  • Racial and ethnic groups more likely to have diabetes
  • Communities with greater prevalence for prediabetes
  • Areas with high mortality rates and emergency room visits due to diabetes 

JHM and UMMC diabetes programs are convenient, respected, and accredited

There are two diabetes programs:

The Diabetes Prevention Program is for those at risk for developing diabetes

The Diabetes Prevention Program uses the Centers for Disease Control and Prevention (CDC)-approved National Diabetes Prevention Program activities. This program has been tailored specifically for those at risk for developing diabetes and has been proven to help:

  • Lower blood glucose levels
  • Lose at least 5% of body weight
  • Increase physical activity at least 150 minutes per week

Diabetes Self-Management Training is for those living with diabetes

Diabetes Self-Management Training uses the American Diabetes Association approved diabetes self-management training activities. This program is for those living with Type 1, Type 2, or gestational diabetes and has been proven to help:

  • Lower A1C by 0.002%
  • Better manage medications
  • Increase healthy lifestyle behaviors to reduce serious diabetes-related complications

Enroll now

Programs are available at various locations from both health systems.

Visit Healthier2gether.org to enroll online or call:

The Diabetes Prevention Program at Johns Hopkins Medicine, 410-614-2701 or University of Maryland Medical Center, 240-749-0109.

Diabetes Self-Management Training at Johns Hopkins Medicine, 443-927-2749or University of Maryland Medical Center, 410-215-2782.

Saint Agnes and LifeBridge Diabetes Health Collaborative

Saint Agnes Lifebridge

Saint Agnes Lifebridge Health Map

The Saint Agnes and LifeBridge Health Diabetes Collaborative will work with our community to develop and foster diabetes and prediabetes prevention and management knowledge and access. Together, we will engage in two major grant activities. We will build upon two successful evidence-based diabetes education activities, National Diabetes Prevention Program (DPP) and ADA-Approved Diabetes Self-Management, to efficiently bring to scale the diabetes prevention and management services needed in West Baltimore.

As a second major grant activity, we will engage with our community partners to improve access to healthy food, currently a barrier to successful diabetes and prediabetes prevention and management activities.

We are community focused. We are the community hospitals located in our five target zip codes; two hospital systems are partnering to serve our community. This proposal leverages the significant experience of Saint Agnes with implementing the National DPP to make diabetes prevention available in West Baltimore. We are not starting from the beginning; but instead, working to bring a small, successful program to scale. We are bringing into this effort strong community-based partner organizations.

Most grant resources are deployed outside the hospital. This is a true community partnership investing in people, such as our National DPP coaches and educators. The coaches, individuals from the community, build the workforce of the communities served.

West Baltimore is a high need area with limited resources. Our community has one of the highest rates of diabetes and pre-diabetes. We are a food desert. We have a high incidence of obesity, diabetes, and other chronic diseases and have little access to safe exercise space.

The Saint Agnes and LifeBridge Health Diabetes Collaborative proposes two major activities:

1. Expand Evidence-Based Diabetes Education

• Expand National Diabetes Prevention Program (DPP) provider capacity. Establishing and credentialing a National DPP program takes time. Fortunately, Saint Agnes has already invested resources to initiate and credential this program. Therefore, the grant funding will begin making an impact in Year 1. We will recruit, train, and support twelve Certified DPP LifeStyle coaches with recruitment coming from within the West Baltimore community.

• Expand ADA-Approved Diabetes Self-Management Training (DSMT) and move this resource from hospital settings and into the community. Providing more resources in the community allows to greater access to services to more affordable services when and where our community needs them.

2. Increase Access to Healthy Foods

Access to healthy foods and supporting behavioral change are critical wrap around services to support patients with diabetes. With this grant, we will leverage existing food resources to support the behavioral and social changes necessary to improve health. Grant funding will expand:

• Baltimarket, a virtual supermarket, with a site coordinator and funds for ordering and delivery.

• Food Rx to all eligible individuals discharged from our hospitals.

• Food as Medicine.

• Promoting Behavior and Lifestyle Changes Through a Social Media Campaign.

• Partnering with Baltimore City LHIC to Address Food Insecurity.

The Ascension Saint Agnes Diabetes Education Center provides comprehensive diabetes education to those who have been diagnosed with diabetes, have prediabetes or have other risk factors for type 2 diabetes. Our team of registered dietitians and nurse educators provide resources to help you self-manage and better understand your condition as well as lifestyle coaches to help you to implement a lifestyle change that can delay or prevent the onset of type 2 diabetes. Learn more about our diabetes self-management education program and diabetes prevention program below.

Diabetes Self Management Education and Support

The Ascension Saint Agnes Diabetes Education program helps you understand how to manage your diabetes.

Whether you have Type 1, Type 2 or gestational diabetes, specialists at Ascension Saint Agnes are here to help. We take the time to explain how diabetes affects your health and daily life. Your specialist works with you to help you manage your condition. And, we offer an education program to help you learn more about living with diabetes. 

Learn how to manage your diabetes 

Ascension Saint Agnes offers diabetes education services. We work with you to develop an individual care plan that fits your lifestyle. Our goal is to help you make good choices without having to give up all the things you love.

The self-management training program is offered in individual sessions or weekly group classes. The program will help you learn about:

  • Diabetes
  • Healthy meal planning and effects of food on blood sugar
  • How to read food labels and use information concerning carbohydrates, fats, sodium, and fiber
  • Benefits of exercise and stress management in your diabetes care
  • How to avoid long-term complications of diabetes
  • Medication management and what to do on "sick days"

Talk to your doctor about diabetes education. A referral is needed for diabetes education classes. Insurance coverage may vary. Talk with your insurance provider about coverage for diabetes education classes. For more information, please call 667-234-3244.

Have your physician complete the diabetes education referral form and fax to 443-708-9355.

Helping prevent diabetes

Do you have prediabetes or other risk factors for type 2 diabetes? Now is the time to take charge of your health and make a change. Prediabetes may be reversed when it’s caught early and by making healthy lifestyle changes. Learn how to make healthy changes by joining the Diabetes Prevention Program at Ascension Saint Agnes Hospital, a CDC-recognized lifestyle change program taught by certified lifestyle coaches.

The Diabetes Prevention Program is a year-long program that focuses on lasting lifestyle changes like regular physical activity, healthy eating, weight loss, and stress management.

The program meets weekly for one hour for the first 6 months and then one to two times per month for the second 6 months.

Diabetes Prevention Program eligibility

To participate in the program, you must:

  • Be 18 years or older
  • Have a body mass index (BMI) of 25 or higher (23 or higher if Asian American)
  • Not be previously diagnosed with type 1 or type 2 diabetes
  • Not be pregnant

You also need to meet one of these requirements:

    1. Had one of these blood test result in the prediabetes range within the past year:
      1. Hemoglobin A1C: 5.7–6.4%.
      2. Fasting plasma glucose: 100–125 mg/dL.
      3. Two-hour plasma glucose (after a 75 g glucose load): 140–199 mg/dL.
  • All medicare participants are required to have a blood test
  1. Be previously diagnosed with gestational diabetes
  2. Received a high-risk result (score of 5 or higher) on the Prediabetes Risk Test

Ready to make a lifestyle change? You have several options to move forward: