Meeting the Challenges of Diabetes Care in a Disadvantaged Community

The Impact of Income and Socioeconomic Status on Diabetes Care

Low income is associated with a higher prevalence of diabetes and diabetes-related complications.¹ Additionally, several studies have shown that mortality risk is higher among people with low socioeconomic status (SES) and diabetes as compared to those with higher SES and diabetes.^2,3 Glycemic management can be very challenging for patients with low SES for several reasons, including the financial burden of increased health care costs and insufficient access to necessary resources to manage the condition (i.e., adequate housing, nutritious food, and health care services), as well as relatively limited educational attainment.⁴ Of these challenges, limited finances is often the most prevalent challenge for patients residing in disadvantaged communities. Health care costs for patients with diabetes can be 2.3 times higher than those without the disease,⁵ and these costs continue to escalate. For example, the cost of insulin has increased significantly over the years, from $100 to $200 per month to $400 to $500 per month, depending on the brand.⁶ Out-of-pocket costs for medications, regimen complexity, and convenience in accessing medications represent some of the many barriers for patients in adhering to taking glucose-lowering agents.^7,8

Poor glycemic control can also be influenced by factors that are not directly limited to patients’ circumstances. Patients with low SES living in disadvantaged communities are less likely to receive diabetes care that meets evidence-based standards^9-11 and have fewer opportunities to meet target treatment goals.¹² Reports also have shown that providers are less likely to perceive patients with low SES as being independent, knowledgeable, responsible, adherent to medical advice and follow-up visits, and willing to pursue healthier lifestyles and behaviors.^13-15 These perceptions can influence provider-patient communication and jeopardize patients’ ability to receive and adhere to appropriate medical advice, leading to poorer outcomes.¹⁶ 

Attention to these issues is critically important and, if neglected, can dramatically influence the ability to achieve and sustain glycemic control. Team care and diabetes self-management education and support repeatedly have been shown to be effective in addressing these problems; however, implementing these services requires resources, time, and expertise.¹⁷ Although it may seem that these barriers are insurmountable, delivering quality health care to patients in a low SES community can be a unique and rewarding experience. To succeed, health care providers need to 1) be prepared to recognize and appreciate the socioeconomic challenges; 2) identify barriers to the specific patient population being treated; and 3) explore partnerships and community-based solutions for success.  

Developing a Model for Chronic Care of Diabetes in a Disadvantaged Community

The Division of Endocrinology and Metabolism has acknowledged this need for evidence-based care for patients residing in low SES communities. In order to expand our services to those in disadvantaged communities, a community-based diabetes clinic was formed within a disadvantaged urban area in the greater Pittsburgh area.

The community was a former home to the steel industry but became a victim of industrial downsizing, with increased rates of unemployment and a subsequent out-migration of younger and more affluent members of the community. These factors encumbered the community with older, sicker, and more socioeconomically challenged individuals. Academic training at major medical centers does not always fully prepare physicians to provide the necessary care for patients with these complex needs. 

The UPMC multidisciplinary diabetes care team has extensive experience in implementing innovative strategies to improve diabetes care in a variety of clinical and community-based settings. These strategies expand the scope and reach of the traditional 1:1 patient-provider interaction and instead emphasize practice redesign, coordinated team-based care, patient self-management, and patient/provider education and support. These approaches also engage the community and leverage local (as well as more distant) resources to optimize clinical outcomes, even in the most challenging settings. In addition, the UPMC diabetes care team has a strong record of aligning these “real-world” approaches with academic expertise to demonstrate the effectiveness of these approaches to diabetes care in community practices.^18-20 UPMC is dedicated to serving the needs of the entire community, with disadvantaged communities often posing the greatest challenges. Recognizing these needs, the UPMC diabetes team launched a specific initiative to understand and improve diabetes care in disadvantaged communities in the Pittsburgh area. The hope is that knowledge gained from projects like this will be more broadly transferrable to similar communities across the nation.

To lead this charge, UPMC recruited endocrinologist Sann Mon, MD, MPH, FACE, to design and implement a diabetes care model to improve diabetes outcomes in disadvantaged communities with a high prevalence of diabetes and its complications. Dr. Mon grew up in Myanmar and completed her initial medical training at the Institute of Medicine in Yangon Myanmar before emigrating to the United States for additional medical training. 

She first completed her Master’s in Public Health (MPH) in Community Health Science at Harvard Medical School, followed by her residency in internal medicine at the Cleveland Clinic and then a fellowship in endocrinology at UPMC. Thus, she has knowledge and experience in meeting health care delivery challenges in different settings. In addition, Dr. Mon is certified in endocrinology, diabetes, and metabolism by the American Board of Internal Medicine (ABIM), as well as obesity medicine by the American Board of Obesity Medicine (ABOM), making her particularly well suited to tackle these complex chronic diseases.

Dr. Mon initially focused on the foundational elements of building a strong and committed multidisciplinary team and forging key partnerships with hospital and community leaders. A critical member of this diabetes chronic care team was a UPMC hospital-based certified diabetes educator (CDE), Carla DeJesus, MS, RD, LDN, CDE, who was already an experienced member of the hospital community and was, therefore, familiar with the many challenges that patients face in this underserved region. The next key element was forming strategic collaborations with local hospital administrators who understood the mission/goals and could facilitate important elements of success, including providing financial support and protected time for the CDE to partner with Dr. Mon, ensuring dedicated space and resources to conduct care and implement initiatives, and advocating for the program when appropriate. This partnership allowed Dr. Mon and the CDE to provide complementary, mutually reinforcing care and education to patients and increased the opportunity and time to address behavioral and psychosocial barriers to care. 

The CDE was able to provide the support that the physician was unable to offer given other clinical and teaching responsibilities. Since ongoing support has been shown to be effective with sustained improvement in glycemic outcomes,²⁰ patients were encouraged to schedule appointments with the CDE in between routine diabetes clinic visits. These follow-up visits opened opportunities for ongoing counseling, behavior modifications, and reinforcement that we believed helped to improve glycemic outcomes in this unique population. In addition, blood glucose readings were uploaded at each CDE visit for review and feedback. Treatment plans and medication adjustments were made in collaboration by the endocrinologist and the CDE. The immediate clinical goal was to reduce
HbA1C levels to below 8%. 

Already familiar with the area and community resources, the CDE helped to develop strong relationships among local primary care physicians, specialists, hospital staff, pharmacists, and social workers. While informed of therapy costs, the CDE was able to maintain up-to-date information on assistance programs that are supported through local foundations, industry, and government agencies. In addition, a nurse coordinator assigned to the clinic helped patients prepare their applications for medication assistance programs. The CDE and nurse coordinator, with their longstanding experience and relationship with the community, assumed responsibilities otherwise performed by a social worker.   

The Diabetes Coordinated Care Program

The specialized, team-based clinic that includes an endocrinologist, CDE, and nurse coordinator is now referred to as the Diabetes Coordinated Care program (DCC). Among a total of 80 patients who have attended the general diabetes clinic, 49 agreed to participate in the DCC program while 31 patients received usual care (UC) (traditional 1:1 visit with the endocrinologist). Comparison of the CC and UC patient characteristics and changes in A1C levels from baseline to 3, 6, and 12 months are presented in Table 1.

The mean age of the 80 patients seen at the diabetes clinic from July 1, 2017 to June 30, 2018 was 57.1 years, with 52.5% being female. The majority of the patients presented with type 2 diabetes (80%), had a mean BMI of 34.1 kg/m2, and an HbA1C of 9.2%. No statistical differences were found in sex, age, BMI, diabetes type, or mean HbA1C between the DCC and UC groups at baseline.  The percentage of patients with HbA1Cs < 8% were compared between the groups. The majority of patients in the DCC group maintained lower HbA1C levels, meeting our immediate target of < 8%, while the UC group experienced a consistent rise in HbA1C over the course of the intervention. At 12 months, the DCC group experienced a significant improvement in HbA1C (p = 0.028) as compared to the UC group. Due to the coordinated care model that relied on a team-based approach, the relative influence of the team members’ efforts is hard to discern. It appears though that both the endocrinologist and the CDE continued to drive and support the sustained improvement in glycemia.

The ability to demonstrate sustained glycemic improvements through our coordinated care model in this challenging community has contributed to ongoing community and organizational support for this important program. UPMC recognized these efforts and presented our team with the UPMC 2018 Excellence in Patient Experience Award. 

The Division of Endocrinology and Metabolism and the associated Diabetes Coordinated Care team at UPMC recognizes the tremendous need for more multidisciplinary, coordinated care of complex diseases such as diabetes. Such models of care have become increasingly important as the prevalence of diabetes continues to rise simultaneously with the need to move towards more effective value-based models of care. The above model is particularly important for targeting care specifically to patients and communities that have the greatest need and most daunting challenges.  

References

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