HUB/Diabetes Education

Diabetes & Hypertension

We’re building a culture of wellness by meeting people where they are, reducing risks from diabetes and hypertension and closing gaps in access. The HUB is a joint program with Chesapeake Regional Healthcare, Chesapeake Rx, Kin n Kids Consulting, and the Chesapeake Health Department that provides no-cost medical management, and social-needs navigation for low-income adults. Participants are followed longitudinally, not just enrolled for a class—so progress sticks.

Get Referred

All individuals are welcome to participate in the program, regardless of insurance.

PCP Referrals are necessary and participants must have either an A1C equal to or above 7 and mean arterial pressure equal to or above 90.

Download the HUB Referral Form.

What the HUB Delivers

The HUB provides a high touch program that addresses the medical and social needs of individuals with high level diabetes. In addition to the support of many Coalition members, the pilot of the program was funded by the Hampton Roads Community Foundation and the Virginia Eye Foundation. It provides low income individuals affected by hypertension and diabetes with individualized case management, needed medications and medical supplies, and counseling support.

Measurable control of chronic disease: HUB participants have achieved an average 20 percent reduction in A1C over time, supported by more than 700 total visits across participants in a recent year. We also connect clients to healthy food, distributing food through the Foodbank of Southeastern Virginia & the Eastern Shore, which helps improve glucose control by addressing nutrition.
A care model aligned to evidence: Intensive lifestyle and community-based supports reduce diabetes incidence and improve HbA1c, consistent with the Diabetes Prevention Program and community health worker interventions literature.

How it Works

Case Management: Nurses, educators, nurse practitioners, and partners co-manage participant goals (A1C, BP, medication adherence).
Diabetes & Nutrition Educators: Produce boxes, pantry referrals, and cooking education support disease control.
Medication Assistance: Screen for eligibility and enroll in manufacturer/340B/copay programs; coordinate $4 generics, prior authorizations, 90-day refills, and other activities to boost adherence.
Neighborhood-based access: Services are offered in trusted community settings for consistency and dignity.

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Diabetes and hypertension drive avoidable Emergency Room use, complications, and costs. Community programs with consistent follow-up help change that trajectory and keep people healthier close to home.