Improving diabetes care from day one

Families receiving a new diabetes diagnosis face one of the most overwhelming transitions in pediatric care. “Start Strong: The New Onset Diabetes Program” was developed with a grant from CareFirst BlueCross BlueShield (CareFirst) to support families during this critical period with care coordination, social drivers of health screening and multi-modal education that build a strong foundation for confident, long-term diabetes management. This effort is part of a unique collaboration between CareFirst and Children’s National to address priority pediatric health issues, including diabetes.

Sarah Lydia Holly, BSN, RN, and lead physician Shideh Majidi, MD, MSCS, discuss the development of this project and their hopes for advancing care for newly diagnosed children and families.

Q: What inspired the development of this program for newly diagnosed children and families?

A: At the time of a diabetes diagnosis, families must quickly learn a new “language” of diabetes, adjust daily routines, adopt new technology and manage the emotional toll. The “Start Strong” program was designed to give families the education, structured follow-up and support they need to confidently manage diabetes from the very beginning.

Q: What makes this program different from the standard care families typically receive at diagnosis?

A: The program builds on the standard care offerings by adding proactive follow-up within days of discharge, consistent outreach from a dedicated care coordinator and early screening for both mental health and social drivers of health. These steps help us tailor care and address challenges early.

Q: What are the key outcomes you hope to see from this program?

A: We want families to stay engaged and feel supported in those first critical months. In practice, this looks like:

• Higher completion of education and follow-up visits
• More consistent mental health and social drivers of health screening, with formalized follow-up and resource referrals.
• Strong knowledge retention through assessments and supplemental modules.
• Expanded Type 2 diabetes education and support.
• A shorter turnaround from diagnosis to insulin pump technology initiation with equitable access for all families.

Q: What have you learned so far?

A: We have learned that intensive education and follow-up right after diagnosis makes a real difference in keeping families connected to care. Early coordination helps resolve underlying barriers before they derail diabetes management.

Q: How will this benefit patients and families?

A: Families benefit from ongoing support, not just at diagnosis but throughout the early months of adjustment. By combining clinical follow-up, psychosocial support and tailored education, the program helps families feel less overwhelmed and more confident.

Q: How might this program serve as a model for other hospitals or diabetes programs?

A: The “Start Strong” program shows the value of embedding care coordination, structured follow-up and screening into the new onset period. The care coordinator model, social drivers of health screening and follow-up, and multimodal education can be adopted by other programs looking to improve engagement and equity in the vulnerable new onset period.

Q: Do you see opportunities to expand or adapt this program in the future?

A: Yes. With continued support, we plan to expand Type 2 diabetes education and increase access to insulin pump technology. We also see opportunities to build out the knowledge assessment and learning module approach so families across diagnoses can receive tailored education. In the long term, core elements like structured follow-up and coordinated social drivers of health support could be adapted to benefit families managing other chronic conditions as well.

Q: Does this program address health disparities?

A: “Start Strong” was intentionally designed to serve all newly diagnosed diabetes patients and families across D.C., Maryland and Virginia. The program places a strong emphasis on reducing disparities by providing coordinated care, consistent follow up on social drivers of health and accessible education for every family.