UVA Primary Care at University of Virginia Health System

Mary Rose Wade and Robert Baker

UVA Primary Care at University of Virginia Health System, RN

UVA Family Medicine
University of Virginia Health System
Charlottesville, Virginia
United States
Mary Rose Wade, RN; Tausha Grim, RN, ANM; Robert Baker, RN

Mary Rose Wade, Tausha M Grim, and Robert Baker create a culture of trust, respect, accountability, stewardship, professionalism, integrity, and excellence and engagement in their everyday communication with our team. They provide incredible patient care behind the scene by identifying patients’ needs and working diligently to meet the needs. It is inspiring to work with a team so dedicated to improving the health of our patients.

In the span of two years, they worked to create a diabetes education program that will support patients at the primary care physician offices.

Two years ago, I was encouraged by Mary Wade at Pantops to become nationally certified diabetes educator to be able to meet patients' needs for diabetes education at the Pantops UVA family medicine clinic.

With Mary's support, I completed the certification in 2017. She even dedicated time to quiz me before the final exam.

Most of our patients did not have diabetes education and we were not able to go to the diabetes education clinic for various reasons (lack of resources, transportation issues, did not want to go to multiple appointments, scheduling issues, did not want to miss work). Mary identified a need for diabetes education to occur at PCP's office. After I was certified Mary reached out to UVA endocrinology and the managers at UVA diabetes education center. With their support, Mary and I applied for accreditation from ADA (American Diabetes Association). We received national accreditation in August 2018.

Mary then communicated to the EPIC team to create the appropriate EPIC referral so providers can communicate the need for diabetes education for their patients. She also communicated to Pantops physicians to encourage referrals for diabetes education. Mary created a work schedule that will allow me to support patients with diabetes 3 times per week in the afternoon hours. At times Mary had to step away from administrative work to support staff within patient care and allow me to complete diabetes education.

The diabetes education has an incredible impact on patients' understanding of their health and the importance of self-care. Mary collaborated with family medicine nurse manager Robert Baker, RN and Tausha Grim, RN, ANM and Dr. Rucker from Stoney Creek Family medicine. As a result of this collaboration in the past fall, we completed a series of group diabetes education classes at UVA Stoney creek clinic for 18 patients. Positive results from the diabetes education class at Stoney Creek: one patient discontinued insulin (he only needs oral medication at this time), some patients lost weight, others implemented healthy lifestyle changes: mindful eating, portion control, signed up for gym membership, etc. We received positive feedback from patients on the program evaluations. They felt supported and cared for. They have an enhanced understating of the disease process and how they can better care for themselves.

Dr. Rucker communicated the success of the diabetes education classes with the family medicine Department chair and other physicians and he requested more diabetes education classes for next year -2019.

Today, Mary Wade held another meeting with family medicine manager Robert Baker, RN, and Tausha Grim, RN to discuss the future of diabetes education. We discussed the logistics, staffing, the need for administrators' involvement and other details that will allow us to move forward with diabetes education for other family medicine clinics.

This is the tentative Proposal for UVA Family Medicine Diabetes self-management Education (DSME) Program for next year - 2019

Mission: Diabetes Self-Management Education for persons with diabetes

Diabetes Self-management behaviors (AADE & ADA):

  • Healthy eating (food choices, carb counting, the effect of diet on health)
  • Being active (how much & what type of exercise)
  • Monitoring (blood glucose, BP, lipids, referrals as recommended depending on diabetes onset & symptoms)
  • Taking medications
  • Problem-solving
  • Healthy coping & screening for depression & eating disorders
  • Reducing risks


Additional education:

  • Mindful eating; microbiota; SMART goals
  • Healthy snacks, meals, and beverages, ideas, and tasting

Format: Group classes with a diabetes educator and PCP or resident every week or every other week for a total of 4 classes.

Location: Any family medicine office.


  • Implementing DSME to support lifestyle modifications to improve quality of life & prevent /reduce complications for persons with diabetes
  • A1C within the recommended range
  • Follow up on recommended screening of BP, lipids, antiplatelet, smoking cessation, retinopathy, nephropathy, neuropathy, PAD, depression, weight, thyroid, Vitamin D, osteoporosis, immunizations, OSA, periodontal disease.
  • Empower patients to take charge of their health.

Referrals to: Ambulatory referral to primary care (CVPE Primary care CL)       


We will address multiple needs for multiple patients in one location. After the DSME classes end patients will follow up with PCP.

The program is low tech, no capital investment.

The program will increase productivity and will create revenue.