Abstract
Background
The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact.
Objective
We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services.
Design
The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups.
Participants
Our study population consisted of 1220 people (740 treatment, 480 control), aged 18–65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020.
Interventions
The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention.
Main Measures
Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization.
Key Results
Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed.
Conclusions
DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

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Data availability
The datasets generated during and/or analyzed during the current study contain individual-level identifiers and protected health information and are not publicly available due to human subjects protection requirements.
References
Strom JL, Egede LE. The Impact of social support on outcomes in adult patients with type 2 diabetes: A systematic review. Curr Diabetes Rep. 2012;12(6):769-781. https://doi.org/10.1007/s11892-012-0317-0
CDC. National Diabetes Statistics Report 2020: Estimates of diabetes and its burden in the United States.; 2020.
Ahmad FB, Anderson RN. The leading causes of death in the US for 2020. JAMA. 2021;325(18):1829-1830. https://doi.org/10.1001/jama.2021.5469
Chen H-Y, Baumgardner DJ, Rice JP. Health-related quality of life among adults with multiple chronic conditions in the United States, Behavioral Risk Factor Surveillance System, 2007. Prev Chronic Dis 2011; 8(1):A09. http://www.cdc.gov/pcd/issues/2011/jan/09_0234.htm.Accessed[date].
Pera PI. Living with diabetes: Quality of care and quality of life. Patient Prefer Adherence. 2011;5:65-72. https://doi.org/10.2147/PPA.S16551
Cunningham P, Carrier E. Trends in the financial burden of medical care for nonelderly adults with diabetes, 2001 to 2009. Am J Manag Care. 2014;20(2):135-142.
Yang W, Dall TM, Beronjia K, et al. Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018;41(5):917-928. https://doi.org/10.2337/DCI18-0007
Ogunwole SM, Golden SH. Social determinants of health and structural inequities—Root causes of diabetes disparities. Diabetes Care. 2021;44(1):11-13. https://doi.org/10.2337/DCI20-0060
Siegel KR, Gregg EW, Duru OK, et al. Time to start addressing (and not just describing) the social determinants of diabetes: Results from the NEXT-D 2.0 network. BMJ Open Diabetes Research and Care. 2021;9. https://doi.org/10.1136/bmjdrc-2021-002524
Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: A scientific review. Diabetes Care. 2021;44(1):258-279. https://doi.org/10.2337/dci20-0053
Saydah S, Lochner K. Socioeconomic status and risk of diabetes-related mortality in the U.S. Public Health Rep. 2010;125:377-388. https://doi.org/10.1177/003335491012500306
Liese AD, Ma X, Reid L, et al. Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina. Pediatric Diabetes. 2019;20(3):321-329. https://doi.org/10.1111/pedi.12822
Cai CX, Li Y, Zeger SL, Mccarthy ML. Social determinants of health impacting adherence to diabetic retinopathy examinations. BMJ Open Diab Res Care. 2021;9:2374. https://doi.org/10.1136/bmjdrc-2021-002374
Frier A, Devine S, Barnett F, Dunning T. Utilising clinical settings to identify and respond to the social determinants of health of individuals with type 2 diabetes—A review of the literature. Health Soc Care Commun. 2020;28(4):1119-1133. https://doi.org/10.1111/hsc.12932
McQueen A, Kreuter MW, Herrick CJ, Li L, Brown DS, Haire-Joshu D. Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes. Health Soc Care Commun. Published online 2021. https://doi.org/10.1111/hsc.13296
Kim EJ, Abrahams S, Marrast L, Martinez J, Hanchate AD, Conigliaro J. Significance of multiple adverse social determinants of health on the diagnosis, control, and management of diabetes. J Gen Int Med. 2021;36(7):2152-2154. https://doi.org/10.1007/s11606-020-05860-9
Chambers EC, McAuliff KE, Heller CG, Fiori K, Hollingsworth N. Toward Understanding social needs among primary care patients with uncontrolled diabetes. J Prim Care Commun Health. 2021;12 2150132720985044. https://doi.org/10.1177/2150132720985044
Shaw K, Killeen M, Sullivan E, Bowman P. Disparities in diabetes self-management education for uninsured and underinsured adults. Diabetes Educ. 2011;37(6):813-819. https://doi.org/10.1177/0145721711424618
Cai CX, Li Y, Zeger SL, McCarthy ML. Social determinants of health impacting adherence to diabetic retinopathy examinations. BMJ Open Diabetes Res Care. 2021;9(1): e002374. https://doi.org/10.1136/bmjdrc-2021-002374
Hill J, Nielsen M, Fox MH. Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. Permanente J. 2013;17(2):67-72. https://doi.org/10.7812/TPP/12-099
American Diabetes Association Professional Practice Committee. 1. Improving care and promoting health in populations: Standards of medical care in diabetes—2022. Diabetes Care. 2022;45:S8-S16. https://doi.org/10.2337/dc22-S001
Ludwig J, Sanbonmatsu L, Gennetian L, et al. Neighborhoods, obesity, and diabetes-a randomized social experiment. N Engl J Med. 2011;365:1509-1519. https://doi.org/10.1056/NEJMsa1103216
Seligman HK, Lyles C, Marshall MB, et al. A pilot food bank intervention featuring diabetes-appropriate food improved glycemic control among clients in three states. Health Affairs. 2015;34(11):1956-1963. https://doi.org/10.1377/hlthaff.2015.0641
Carrasquillo O, Lebron C, Alonzo Y, et al. Effect of a community health worker intervention among Latinos with poorly controlled type 2 diabetes The Miami Healthy Heart Initiative Randomized Clinical Trial. JAMA Intern Med. 2010;177(7):948-954. https://doi.org/10.1001/jamainternmed.2017.0926
Hessler D, Bowyer V, Gold R, Shields-Zeeman L, Cottrell E, Gottlieb LM. Bringing social context into diabetes care: intervening on social risks versus providing contextualized care. Curr Diabetes Rep. 2019;19(6): 30. https://doi.org/10.1007/s11892-019-1149-y
Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):26-32. https://doi.org/10.1542/peds.2009-3146
National Association of Community Health Centers Inc, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association. PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences Paper - Version of PRAPARE for Implementation as of September 2, 2016.; 2016. Accessed March 22, 2022. https://prapare.org/wp-content/uploads/2021/10/PRAPARE-English.pdf
Cook JT, Frank DA, Casey PH, et al. A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers. Pediatrics. 2008;122(4):e867-e875. https://doi.org/10.1542/peds.2008-0286
Puterman E, Haritatos J, Adler NE, Sidney S, Schwartz JE, Epel ES. Indirect effect of financial strain on daily cortisol output through daily negative to positive affect index in the Coronary Artery Risk Development in Young Adults Study. Psychoneuroendocrinology. 2013;38(12):2883-2889. https://doi.org/10.1016/j.psyneuen.2013.07.016
Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Int Med. 2012;27(8):992-1000. https://doi.org/10.1007/S11606-012-2082-9
Peek ME, Ferguson M, Bergeron N, Maltby D, Chin MH. Integrated community-healthcare diabetes interventions to reduce disparities. Curr Diab Rep. 2014;14(3):467. https://doi.org/10.1007/s11892-013-0467-8
Steinsbekk A, Rygg LØ, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Services Research. 2012;12:213. https://doi.org/10.1186/1472-6963-12-213
Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults With Type 2 Diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25:1159-1171. https://doi.org/10.2337/diacare.25.7.1159
Jortberg BT, Miller BF, Gabbay RA, Sparling K, Dickinson WP. Patient-centered medical home: how it affects psychosocial outcomes for diabetes. Curr Diabetes Rep. 2012;12(6):721-728. https://doi.org/10.1007/s11892-012-0316-1
Hossain WA, Ehtesham MW, Salzman GA, Jenson R, Calkins CF. Healthcare access and disparities in chronic medical conditions in urban populations. Southern Med J. 2013;106(4):246-254. https://doi.org/10.1097/SMJ.0b013e31828aef37
Smith JJ, Berman MD, Hiratsuka VY, Frazier RR. The effect of regular primary care utilization on long-term glycemic and blood pressure control in adults with diabetes. J Am Board Family Med. 2015;28(1):28-37. https://doi.org/10.3122/jabfm.2015.01.130329
Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: Risks, management, and learnings from other national disasters. Diabetes Care. 2020;43(8):1695-1703. https://doi.org/10.2337/dc20-1192
Gregg EW, Sophiea MK, Weldegiorgis M. Diabetes and covid-19: Population impact 18 months into the pandemic. Diabetes Care. 2021;44(9):1916-1923. https://doi.org/10.2337/dci21-0001
Tanumihardjo JP, Gunter KE, Chin MH, et al. Integrating technology and human capital to address social needs: Lessons to promote health equity in diabetes care. J Health Care Poor Underserved. 2021;32(2):241-261. https://doi.org/10.1353/hpu.2021.0061
Wilkes AE, Bordenave K, Vinci L, Peek ME. Addressing diabetes racial and ethnic disparities: lessons learned from quality improvement collaboratives. Diabetes Manag (Lond). 2011;1(6):653-660. https://doi.org/10.2217/dmt.11.48
Gunter KE, Peek ME, Tanumihardjo JP, et al. Population health innovations and payment to address social needs among patients and communities with diabetes. Milbank Quart. 2021;99(4):928-973. https://doi.org/10.1111/1468-0009.12522
Funding
This study was funded by the Merck Foundation’s Bridging the Gap: Reducing Disparities in Diabetes Care.
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The authors wish to thank the research staff who helped with this study, including Aisha Gilmore, Ritu Ghosal, Denise Baldwin, and Megan Holtorf. Additionally, the authors wish to express appreciation to the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office.
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Roth, S.E., Gronowski, B., Jones, K.G. et al. Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes. J GEN INTERN MED 38 (Suppl 1), 38–44 (2023). https://doi.org/10.1007/s11606-022-07920-8
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DOI: https://doi.org/10.1007/s11606-022-07920-8
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