For Dr. Bruce Block, a physician at UPMC Shadyside's Family Health Center, providing better diabetes care has been an evolving process.

In the 1980s, he developed and implemented a computer system to tell doctors of the tests patients needed and when they needed them, realizing, he said, that he "couldn't keep track of everything" on his own.

Then the practice set up a reminder system listing patients who haven't been in for treatment for at least three months. A staff member contacts them and, if necessary, helps with transportation costs or other needs.

But what happens between doctor visits, he also realized, is also important. So he helped to found the Centers for Healthy Hearts and Souls, which operates support groups to encourage patients to exercise, lose weight and take other steps to control the disease.

Like Dr. Block, communities around the nation are using a wide variety of strategies to try improve diabetes care. They range from computer support for physicians to covering patients' co-pays for prescription drugs to providing patients with encouragement, sometimes through one-on-one coaching by neighborhood pharmacists.

In Pennsylvania, a state commission is working on ways to improve diabetes care statewide. Some states already have mounted efforts to battle the disease.

Washington, for example, began working to help physician practices in 1999, relying in part on a chronic care model developed by Dr. Edward Wagner, director of the MacColl Institute for Healthcare Innovation in Seattle. The model, which Pennsylvania also plans to use uses a team approach for care, helps patients set goals to improve their overall health, and uses computers to track patients, their medical tests and other needs.

Washington holds training sessions, known as collaboratives, and works with physicians' practices to help them use electronic tracking systems, said Jan Norman, director of the chronic disease prevention unit for the state Department of Health.

So far, more than 140 physician practices have participated in the training sessions, she said. They care for nearly one-third of the state's 307,000 diabetic patients.

"We know that change is going in the right direction," she said.

Practices also have reported improvements in several measures of patient care, including blood pressure and cholesterol levels and hemoglobin A1C, which provides an average of blood sugar levels over a period of months.

Announced in 2003 and paid for in part by federal and state funds, Vermont's battle against diabetes and other chronic diseases is "not just about disease management," said Dr. Susan Besio, the state's director of health care reform implementation. "It's about changing the way providers practice their care, the way they're reimbursed, information technology tools, giving patients access to patient education and other self-help opportunities, as well as ensuring communities have the opportunity to be healthy."

The program includes "healthier living" workshops around the state that are free to participants and provide information about exercise and nutrition counseling. More than 500 people have enrolled, and their medical and emergency department visits have decreased by 60 percent in the past year, Dr. Besio said.

In Pennsylvania, Montour County-based Geisinger Health System has implemented computer upgrades to provide more than 200 doctors, most of them primary care physicians, with more information about the system's nearly 21,000 diabetes patients.

Physicians are given computerized alerts of services that diabetes patients need to receive, said Dr. Mark Selna, associate chief innovation officer.

Lab tests are taken ahead of time so results would be available at clinic visits, and a system was set up to notify diabetes patients, by letter and telephone if necessary, if they hadn't been in for an appointment for seven months.

"The process we re-engineered in the past two years shows we're making a difference in measures that matter," Dr. Selna said.

From January 2006 to June 2007, the number of diabetes patients with A1C levels less than 7 increased from 32 to 37 percent, he said. The number of those with blood pressure levels less than 130/80 rose from 38 percent to 47 percent.

The University of Pittsburgh Medical Center has 325 physicians utilizing tools for diabetes management in the electronic health record. About 250 physicians receive practice-specific reports on diabetes care regarding indicators such as A1C and cholesterol levels.

With federal funding through U.S. Rep. John Murtha, the Pitt Diabetes Institute has helped to establish the Pittsburgh Regional Initiative for Diabetes Education, a collaboration to improve diabetes education and chronic care management.

UPMC Health Plan also has announced a joint effort, with the Diabetes Institute, that plans to use an electronic system to track quality measures, service utilization and outcomes for diabetes patients. Strategies planned to help patients learn to better manage their disease include education programs, case management and coaching over the telephone.

Officials want to get more members linked to a family doctor that can serve as their "medical home," said John Lovelace, a vice president for the health plan. He noted that less than 60 percent of those receiving Medicare and Medicaid, who are targeted by the program, had been to the same family doctor at least twice in the same year.

Too often, he said, plan members who do not receive good ongoing medical care need emergency treatment or other hospital care.

Local companies also are participating in the Diabetes Ten City Challenge, an effort to help patients better manage their diabetes.

The Ten City Challenge is modeled in part after the Asheville Project, a diabetes self-management program that has shown promising results in reducing patients' A1C levels and lowering health care costs.

Employers participating in the Ten City Challenge typically pay for coaching sessions with pharmacists and for diabetes medications and related supplies. Community pharmacists are trained to coach people on how to manage their disease, including setting goals -- for example, to lose weight or improve their diets -- tracking their condition and using medications properly.

About 1,300 employees, dependents and retirees from more than 30 companies are participating in the Diabetes Ten City Challenge, according to William Ellis, chief executive officer of the American Pharmacists Association Foundation, which conducts the program.

Locally, eight employers -- among them Carnegie Mellon University, Duquesne University, Development Dimensions International, H.J. Heinz, Respironics, and the Ellwood Group -- are participating in the challenge through the Pittsburgh Business Group on Health's LivingMyLife program.

Nearly 200 employees, retirees and family members have enrolled, said Christine Whipple, the business group's executive director. More than 80 pharmacists have completed training to provide the coaching.

Giant Eagle also has joined the Ten City Challenge, and more than 120 non-union employees and their family members are participating.

Rachel Henderson, a Giant Eagle pharmacist, coaches 42 people and maintains regular contact with their physicians. Though she usually meets with her clients at the stores, she has met with one husband and wife at their home and another client at a Starbucks. In some cases, she takes patients for walks during the counseling sessions to encourage them to exercise.

Marian Lee, 58, of Wilkinsburg, a Carnegie Mellon employee who enrolled in the program about a year ago, said not having to pay for her diabetes medication and supplies has been a big help.

She said she now takes her diabetes more seriously. She tests her blood sugar more often and her A1C levels have dropped.

In another effort, eight federally qualified health centers in the region launched a collaborative venture two years ago to improve diabetes care. The federally funded centers provide care regardless of ability to pay. Centers around the nation also are working to improve chronic care management as part of an effort to eliminate health disparities, said Jayne Bertovich, director of the local effort.

Earlier this year, more than 1,700 patients were participating in the initiative, known as the Western Pennsylvania Health Disparities Collaborative.

The health centers have installed patient registry computer systems to track patient outcomes and taken other steps to improve care.

To improve screening for eye disease, for example, the East Liberty Family Health Center obtained donated equipment and help from an ophthalmology practice to conduct the screenings each month, said Dr. Eileen Boyle, a physician at the center.

The center also began processing hemoglobin A1C tests on site, allowing doctors to discuss the results the same day rather than telephoning patients later.

Overall, A1C levels have improved, she said. Documented goal setting, which involves forms signed by patients about the health goals they plan to achieve, has gone from zero to more than 50 percent.

Dr. Block of UPMC Shadyside's Family Health Center said some of the initiatives he has implemented over the years would be a challenge to put in place without support from grants and an academic medical setting. He also donates his time.

Incentives in the payment system to deliver improved care would be preferable, he said.

While insurers have been reluctant to take that step on a broad scale, "that's starting to change, and I think part of that is pressure from business," Dr. Block said, noting that companies are increasingly reluctant to shoulder increases in health care costs.

"Providing better preventive care for diabetes patients may result in higher costs in the short term," he said. "Our hope is that businesses and insurers will save money in the long run, when their employees and their families are in better health."