The Diabetes Initiative, led by Health Cities, is aimed at transforming the prevention and management of type 2 diabetes through innovative solutions. The initiative will collaborate with care providers across Alberta to implement tools and care models that support both prevention and ongoing management of type 2 diabetes. Its goal is to validate and scale these solutions within primary care and strengthen the health system’s ability to address diabetes effectively.
The initiative envisions a future where Albertans can prevent complications from type 2 diabetes through pathways that are:
This initiative focuses on six key areas, working toward improved health outcomes, equitable care, and increased access for Albertans at risk of or living with type 2 diabetes. It does this by supporting effective management for those already diagnosed and helping to prevent or delay the onset of type 2 diabetes for those at risk.
The initiative is structured across five strategic phases, ensuring real-world input, measurable results, and scalable insights. The timeline reflects our commitment to responsive design, collaborative delivery, and system-wide impact.
Identify key diabetes management challenges or needs and develop novel care pathways.
Goal: Understand gaps in diabetes care, gather insights, and design patient-centered pathways.
Identify innovative solutions to enhance diabetes management by addressing specific needs or gaps.
Goal: Select feasible, effective, and patient-aligned solutions ready for testing.
Test and evaluate new care pathways and technologies with multiple primary care hubs.
Goal: Operationalize promising pathways and solutions in real-world primary care settings.
Scale and validate the initiative with additional targeted primary care hubs from across Alberta.
Goal: Demonstrate effectiveness and adaptability across diverse care environments.
Analyze findings, create policy recommendations, and disseminate results through reports, publications, and more.
Goal: Generate evidence to inform decision-making, guide practice, and support system-wide adoption.
The Diabetes Initiative is a technology-enabled, team-based care initiative designed to prevent and manage Type 2 diabetes across Alberta. Targeting individuals either at risk or already diagnosed, the initiative leverages virtual tools, innovative care models, and Primary Care Networks (PCNs) to improve access to care, strengthen self-management, and enhance long-term health outcomes. Building on the success of Health Cities’ virtual home health monitoring initiatives, the initiative develops scalable solutions that align with provincial strategies, support healthier communities, and advance more connected, efficient, and patient-centered care.
View the individual Diabetes Initiative projects below.
Building on a remote monitoring model first implemented with Camrose Primary Care Network and Kalyna Country Primary Care Network, Health Cities is supporting McLeod River Primary Care Network and Bighorn Primary Care Network as they adapt similar technology-enabled diabetes supports for rural communities in west-central Alberta. The project serves communities including Edson and Hinton, with a focus on improving access to ongoing diabetes support and helping people stay connected to their care teams between appointments. The model combines home health monitoring, and team-based primary care to provide more timely insight into diabetes management and support earlier follow-up when concerns arise. As part of the expansion, representatives from Camrose and Kalyna Country PCNs are sharing implementation experience, workflow learnings, and practical guidance to support adoption of the remote monitoring model in new care settings.
Through this work, McLeod River and Bighorn PCNs are helping extend a proven implementation approach into additional rural communities while generating further insights on patient engagement, clinical workflow, and sustainable use of remote monitoring in primary care. Learnings from the project will contribute to the continued development of a scalable virtual diabetes care model for communities across Alberta.
Explore Additional Remote Monitoring Implementations
Crowfoot Village Family Practice is partnering with Health Cities to validate a standardized diabetes care model that helps patients and care teams better prepare for diabetes-related appointments. As one of Alberta’s largest family medicine practices, Crowfoot Village Family Practice supports a large and diverse patient population and is exploring new approaches to improve care coordination, strengthen patient engagement, and create a more consistent experience for people living with diabetes.
The project combines a standardized approach to diabetes care planning with a technology-enabled appointment preparation process that helps patients and providers gather and review important information before visits occur. By improving readiness for appointments, the project aims to enhance patient experience, improve clinic workflow efficiency, and create more meaningful interactions between patients and care teams. The project will help inform a scalable approach that can support diabetes care delivery in primary care settings across Alberta.
Palliser Primary Care Network is partnering with Health Cities to validate a remote diabetes monitoring care model that helps people living in rural communities stay connected to their primary care team. Serving communities including Medicine Hat, Redcliff, Bow Island, Brooks, and Bassano, the project focuses on adults living with diabetes who reside significant distances from their clinic, addressing common challenges related to travel, access, and ongoing monitoring. By supporting people to track and share health information from home, the model aims to improve continuity of care, strengthen self-management, and help care teams identify concerns earlier.
The project explores how remote monitoring information can be incorporated into existing primary care workflows using electronic medical record patient portals. The project will generate practical insights into how remote monitoring can be integrated into routine diabetes care and inform a scalable approach that can support rural communities across Alberta.
Our team reviews all submissions and inquiries related to the Diabetes Initiative. We will follow up with proponents whose proposals show alignment and potential, or where further information is needed.
To contact our team directly, please email projects@healthcities.ca.
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