Professional Documents
Culture Documents
Recommendations
1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines,
include social community support, and are made collaboratively with pa-
tients based on individual preferences, prognoses, comorbidities, and in-
formed financial considerations. B
1.2 Align approaches to diabetes management with the Chronic Care Model.
This model emphasizes person-centered team care, integrated long-term
treatment approaches to diabetes and comorbidities, and ongoing collab-
orative communication and goal setting between all team members. A
1.3 Care systems should facilitate in-person and virtual team–based care, in-
cluding those knowledgeable and experienced in diabetes management
as part of the team, and utilization of patient registries, decision support
tools, and community involvement to meet patient needs. B
1.4 Assess diabetes health care maintenance (Table 4.1) using reliable and Disclosure information for each author is
relevant data metrics to improve processes of care and health outcomes, available at https://doi.org/10.2337/dc23-SDIS.
with attention to care costs. B Suggested citation: ElSayed NA, Aleppo G, Aroda
VR, et al., American Diabetes Association. 1.
Improving care and promoting health in po-
Population health is defined as “the health outcomes of a group of individuals, includ- pulations: Standards of Care in Diabetes—2023.
Diabetes Care 2023;46(Suppl. 1):S10–S18
ing the distribution of health outcomes within the group”; these outcomes can be
measured in terms of health outcomes (mortality, morbidity, health, and functional © 2022 by the American Diabetes Association.
status), disease burden (incidence and prevalence), and behavioral and metabolic fac- Readers may use this article as long as the
work is properly cited, the use is educational
tors (physical activity, nutrition, A1C, etc.) (1). Clinical practice recommendations for and not for profit, and the work is not altered.
health care professionals are tools that can ultimately improve health across popula- More information is available at https://www.
tions; however, for optimal outcomes, diabetes care must also be individualized for diabetesjournals.org/journals/pages/license.
diabetesjournals.org/care Improving Care and Promoting Health in Populations S11
each patient. Thus, efforts to improve of the population, such as young adults 6. Health systems (to create a quality-
population health will require a combi- and individuals with complex comorbid- oriented culture)
nation of policy-level, system-level, and ities, financial or other social hardships,
patient-level approaches. With such an and/or limited English proficiency, face A 5-year effectiveness study of the
integrated approach in mind, the Ameri- particular challenges to goal-based care CCM in 53,436 people with type 2 diabe-
can Diabetes Association (ADA) highlights (5–7). Even after adjusting for these tes in the primary care setting suggested
the importance of patient-centered care, patient factors, the persistent variability that the use of this model of care delivery
defined as care that considers individual in the quality of diabetes care across reduced the cumulative incidence of
patient comorbidities and prognoses; is health care professionals and prac- diabetes-related complications and all-
respectful of and responsive to patient tice settings indicates that substan- cause mortality (10). Patients who were
preferences, needs, and values; and en- tial system-level improvements are enrolled in the CCM experienced a re-
sures that patient values guide all clinical still needed. duction in cardiovascular disease risk by
decisions (2). Furthermore, social deter- Diabetes poses a significant financial 56.6%, microvascular complications by
and identifying, developing, and engaging a growing variety of applications and content and skills, behavioral strategies
community resources and public policies services using two-way video, smartphones, (goal setting, problem-solving), and en-
that support healthy lifestyles (29). The wireless tools, and other forms of tele- gagement with psychosocial concerns.
National Diabetes Education Program communications technology (40). Often Increasingly, such support is being ada-
maintains an online resource (cdc.gov/ used interchangeably with telemedicine, pted for online platforms that have the
diabetes/professional-info/training.html) telehealth describes a broader range of potential to promote patient access to
to help health care professionals design digital health services in health care deliv- this important resource. These curricu-
and implement more effective health ery (41). This includes synchronous, asyn- lums need to be tailored to the needs of
care delivery systems for those with dia- chronous, and remote patient monitoring. the intended populations, including ad-
betes. Given the pluralistic needs of peo- Telehealth should be used comple- dressing the “digital divide,” i.e., access
ple with diabetes and that the constant mentary to in-person visits to optimize to the technology required for imple-
challenges they experience vary over the glycemic management in people with mentation (53–56).
course of disease management (complex unmanaged diabetes (42). Increasingly,
Access to Care and Quality Improvement personalized care goals (7,73). (Also see framework for educating health care
The Affordable Care Act and Medicaid COST CONSIDERATIONS FOR MEDICATION-TAKING professionals on the importance of
expansion have increased access to BEHAVIORS, above, regarding cost-related SDOH (84). Furthermore, there are re-
care for many individuals with diabetes, barriers to medication use.) sources available for the inclusion of stan-
emphasizing the protection of people dardized sociodemographic variables in
with preexisting conditions, health pro- TAILORING TREATMENT FOR electronic health records to facilitate the
motion, and disease prevention (60). In SOCIAL CONTEXT measurement of health inequities and
fact, health insurance coverage increased the impact of interventions designed to
from 84.7% in 2009 to 90.1% in 2016 for Recommendations
reduce those inequities (65,84,85).
adults with diabetes aged 18–64 years. 1.5 Assess food insecurity, housing
SDOH are not consistently recognized
Coverage for those aged $65 years re- insecurity/homelessness, financial
and often go undiscussed in the clinical
mained nearly universal (61). Patients barriers, and social capital/social encounter (77). Among people with
who have either private or public in- community support to inform chronic illnesses, two-thirds of those who
headed by single mothers. The food obtain nutritious food more regularly Migrant farmworkers encounter nu-
insecurity rate in individuals with diabe- (98). merous and overlapping barriers to re-
tes may be up to 20% (90). Additionally, ceiving care. Migration, which may occur
the risk for type 2 diabetes is increased Homelessness and Housing Insecurity as frequently as every few weeks for
twofold in those with food insecurity Homelessness/housing insecurity often farmworkers, disrupts care. In addition,
(81) and has been associated with lower accompanies many additional barriers cultural and linguistic barriers, lack of
engagement in self-care behaviors and to diabetes self-management, including transportation and money, lack of avail-
medication use, depression, diabetes food insecurity, literacy and numeracy able work hours, unfamiliarity with new
distress, and worse glycemic manage- deficiencies, lack of insurance, cognitive communities, lack of access to resour-
ment when compared with individuals dysfunction, and mental health issues ces, and other barriers prevent migrant
who are food secure (91–93). Older (99). The prevalence of diabetes in the farmworkers from accessing health care.
adults with food insecurity are more homeless population is estimated to be Without regular care, those with diabetes
around 8% (100). Additionally, people
diabetes care and education specialists be lifelong (112). These factors are rarely 3. Haire-Joshu D, Hill-Briggs F. The next generation
should ensure they provide easy- addressed in routine treatment or disease of diabetes translation: a path to health equity.
Annu Rev Public Health 2019;40:391–410
to-understand information and reduce management but may be underlying 4. Kazemian P, Shebl FM, McCann N, Walensky
unnecessary complexity when develop- reasons for lower engagement in self- RP, Wexler DJ. Evaluation of the cascade of
ing care plans with patients. Interven- care behaviors and medication use. diabetes care in the United States, 2005–2016.
tions addressing low health literacy in Identification or development of com- JAMA Intern Med 2019;179:1376–1385
munity resources to support healthy 5. Kerr EA, Heisler M, Krein SL, et al. Beyond
populations with diabetes seem effec-
comorbidity counts: how do comorbidity type and
tive in improving diabetes outcomes, in- lifestyles is a core element of the CCM severity influence diabetes patients’ treatment
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management. Combining easily adapted currently a paucity of evidence regarding 6. Fernandez A, Schillinger D, Warton EM, et al.
Language barriers, physician-patient language
materials with formal diabetes education enhancing these resources for those
concordance, and glycemic control among insured
demonstrates effectiveness on clinical most likely to benefit from such interven-
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