Despite the proven benefits of diabetes selfmanagement education and support (DSMES) in improving patient outcomes and reducing complications, the participation rate among eligible individuals remains alarmingly low. Millions of people with diabetes who could gain valuable tools to help manage their disease, optimize their health outcomes, and avoid serious complications are not utilizing this critical resource. This gap not only undermines personal health outcomes but also strains health care systems, raising questions about the barriers preventing widespread access and engagement in DSMES programs.
Over the past 10 years of my career, I’ve worked to expand the reach of DSMES to vulnerable populations and bring attention to the impact diabetes care and education specialists (DCESs) have on a population’s health. These efforts are what led to becoming the 2024 ADCES Power of Our Impact award recipient. Although the recognition is deeply rewarding, the true impact has been the result of a collaborative effort involving many key influencers. Here is my story.
I served as the quality coordinator of an accredited hospital-based diabetes education program in Reading, Pennsylvania. Our program was located in an inner-city ambulatory center serving some of the most underserved neighborhoods and vulnerable residents of the area. Our program was thriving with referrals from our family practice physicians across the street who knew us well—and would often send patients walking in with a referral in hand just as they were leaving their appointment.
Most of our patients were enrolled in Medicaid, and so there were no out-of-pocket costs for their appointments. Although this was great for engagement, it didn’t help us build a business plan when we needed to grow our team.
With poor Medicaid reimbursement rates, we struggled to get our finance team to agree to add on another CDCES, which brings me to a key DSMES influencer in improving DSMES outreach, the community health workers (CHW). We were given the green light on hiring a CHW to fill the role of a Diabetes care community coordinator (DCCC). Not only did our DCCC solve for our patient’s nonmedical needs, such as housing, transportation, and food access, but the implementation of the role helped our program become more efficient. We added group education programs, partnered with a local community-based organization to integrate a fruit and vegetable prescription incentive into our program, and were able to implement a hospitalization transition of care initiative to help patients successfully shift their diabetes care from inpatient to outpatient resources.
Building strong relationships with provider allies was a crucial next step for increasing access to our DSMES. Over the next year, my team built a business plan to expand our program’s reach to other primary care providers (PCPs) in our community.
We did our best to replicate the nuggets of success we had at our downtown campus, such as providing DSMES in other ambulatory centers strategically located in walking distance to the other PCP offices. We set up lunch and learns about diabetes technology, provided cheat sheets for office staff to navigate ordering diabetes supplies, and offered an elective diabetes training for the family practice residency program.
As our program grew to different patient populations, we started facing challenges we didn’t see as often with the Medicaid population. Barriers such as out-of-pocket costs for DSMES and prescription formulary restrictions were making it more difficult for our patients to access DSMES, self-care devices, and even medications.
How are we to increase access to DSMES to patients who have to reach their $5,000 insurance deductible before they have any coverage for our services? Why did providers need to go through intensive prior authorizations to get their patients on a medication that was standard of care? Why is one patient able to benefit from a continuous glucose monitor while another similar patient is denied? More importantly, who was making these decisions?
To find answers, I shifted my career and took on a role within an employer-sponsored health plan managing the chronic care and health outcomes for a chicken processing company’s health plan. Many of the plan members were from the communities I had worked in while at the health system, but with poor health benefit literacy, demanding work schedules, and language barriers, accessing health care for themselves was a challenge.
The employer recognized this gap and decided to provide employees with on-site primary care to help tamp down rising costs associated with poor preventive care engagement, increasing ER utilization, and preventable hospital spend. Because on-site care is convenient, employees received care they might not otherwise get due to transportation or time away from work. But a deep dive into the health plan’s claims showed a rising trend in chronic conditions and a potential increase in costs for these members despite their access to primary care.
At first glance, chronic condition health spend looked low, but the data showed multiple gaps in care. Participants weren’t taking medications as prescribed, and clinical metrics were considerably off, likely leading to costly complications.
To respond, we decided to layer on an innovative chronic condition program, which integrated DSMES into the on-site primary care office. This provided us with a return on investment that included improved worker productivity, employee satisfaction, health outcomes, cost-effective care, and of course, health equity.
We then looked at the efficiency of traditional cost-containment strategies outlined in the health plan (eg, copays, deductibles, pharmacy formularies, prior authorizations). We found many were ineffective at reducing costs and resulted in poor quality outcomes by delaying care and limiting access. By removing this friction, the health plan members gained access to the tools they needed to better manage their health. Members no longer had to meet their deductible before having coverage for DMSES and prior authorizations, and copays were removed for diabetes-related medications and supplies when members were actively engaged in DSMES services.
The employer’s health plan deployed a strategy to retool their member health care resources with concentrated efforts around equitable health benefits. Program outcomes included a reduction in prescription waste, increased employee satisfaction, improved provider satisfaction, and an average 3.0 drop in A1C, all while keeping overall health plan spend flat.
From collaborating with DCCCs who are an often underrecognized yet integral part of the diabetes care team to leveraging support from provider allies and health plan sponsors who recognize their influence on eliminating barriers, the progress we’ve made in increasing access to DSMES is a shared achievement. This collaboration has not only expanded DSMES’s reach but also reinforced the idea that meaningful change in health care can be made, even at a local level, through a collective commitment to improving health outcomes for everyone.
Lizzy Hawk, MS, RDN, CDCES, is employed at Diverge Health in Reading, Pennsylvania.