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Three New Programs Improve Diabetes Care in Low-Income Areas

Feb 16, 2012

In Los Angeles and Chicago, programs designed to improve the management of diabetes in underserved populations appear to be working.

According to Peter Huckfeldt, PhD, of the RAND Corporation in Santa Monica, CA, two initiatives in the Los Angeles — one run by the Los Angeles County Department of Health Services, and one integrating case management and clinical pharmacy programs in primary care clinics — saw significant reductions in A1c and LDL cholesterol levels after implementation. And preliminary results from a four-pronged approach in Chicago targeting health centers, patients, providers, and community resources also appear promising, according to Monica Peek, MD, MPH, of the University of Chicago, and colleagues.

In Los Angeles, the adult diabetes rate increased nearly 50% in the past decade, concentrated in the low-income populations. The diabetes rate is twice as high among Hispanics and blacks as among non-Hispanic whites. The researchers examined two programs started in the healthcare safety net to help control diabetes in these underserved populations.

The first, run by the county health department, involved a short-term intensive intervention delivered by a team comprised of an endocrinologist, three nurses, two nurse practitioners, community workers, and pharmacists under the guidance of the medical director of a comprehensive health center.

The program, which allows patients to receive an assessment and treatment at a single visit, has been implemented at six centers in Los Angeles County. Patients are able to fill prescriptions for little to no cost within the same building where they receive the assessment.

Before the program started, average HbA1c ranged from 8.8% to 11.9% and LDL cholesterol levels ranged from 95 to 116 mg/dL across the six centers. After implementation, HbA1c dropped to 6.8% to 7.9%, and LDL cholesterol fell to 73 to 97 mg/dL. “Clearly, benefits are derived from intensive, short-term care management,” the authors wrote. “It is yet to be determined whether or not these improvements can be sustained in primary care.”

The second approach in Los Angeles involved the use of integrated case management (lifestyle counseling and education about diet, exercise, and insulin administration) and clinical pharmacy programs, in which pharmacists help manage the use of medications. The two programs were incorporated into primary care clinics in the community.

The researchers surveyed 244 patients from two clinic locations to assess how well the program was working. Most were Hispanic (89%) and non-U.S. citizens (71%). Only 1% had private insurance, and 62% were uninsured.

Among the patients participating in case management, average HbA1c fell from 9.4% in the year before enrollment to 8% in the first year and 8.1% in the second year. Average LDL cholesterol levels also improved. The findings were similar among patients who participated in the clinical pharmacy program.

Although both approaches improved disease control in the short term, Huckfeldt and colleagues noted the program involving primary care clinics was less labor-intensive and possibly less expensive than the county program. Even so, both programs “could ultimately reduce costs for the county through avoided disease complications and the associated costs,” they wrote.

“The challenge is to understand the essential aspects of these interventions; refine their design so that they are more cost-effective and fiscally feasible; and identify long-term health and cost effects.”

Peek and colleagues described a program started on the south side of Chicago, a largely low-income, black community, which, much like Los Angeles, has an elevated rate of diabetes.

Because racial and ethnic disparities in diabetes are related to multiple causes, according to the researchers, the initiative involved a multifactorial approach.

“Our initiative neatly aligns with, and can inform the implementation of, the accountable care organization — a delivery system reform in which groups of providers take responsibility for improving the health of a defined population,” they wrote.

The program included four main aspects:

  • Six health centers formed a quality improvement team with the goal of achieving system-level quality improvement. The teams meet periodically with those from other centers to share best practices
  • Culturally tailored patient education is delivered in a 10-week series of classes, which include instruction in patient-provider communication and shared decision-making
  • Providers undergo communication training in a four-workshop series
  • Outreach is performed to create community partnerships with organizations and businesses that support diabetes self-care at home

Though analysis of the efficacy of the program is in the preliminary stages, indicators of the health centers’ ability to provide chronic illness care suggest that the approach is effective.

Practice Pearls:
  • In a different study, preliminary results from a four-pronged approach in Chicago targeting health centers, patients, providers, and community resources also appear promising in diabetes management.
  • A study found that two initiatives in Los Angeles saw significant reductions in A1c and LDL cholesterol levels after implementation.

Huckfeldt P, et al “Diabetes management for low-income patients in Los Angeles: two strategies improved disease control in the short term” Health Aff 2012; 31: 168-176.