Diabetes is now an epidemic, with 38.4 million people in America living with the condition and well over a quarter of the country (97.6 million) classified as having prediabetes. And like most public health crises, it isn’t affecting all communities evenly. Black, Native American, and Hispanic individuals experience diabetes at more than double the rate of White people due to a variety of systemic inequities and cultural factors.
In some geographic areas, like Texas, the stark disparities are claiming thousands of limbs — and thousands of lives — due to complications from untreated foot ulcers that lead to lower extremity amputations and a resulting five-year mortality risk of nearly 60%.
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As The New York Times explained in a recent feature, Texas has one of the highest rates in the nation for diabetes-related amputations, accounting for approximately 52 per 100,000 hospital admissions. In places like San Antonio, which has a large Mexican American population, providers estimate that nearly half of adults over 40 are likely to have diabetes, contributing to the region’s excessive mortality rate tied to the condition.
A large number of these people are uninsured or on Medicaid, are most comfortable communicating in languages other than English, and may have additional comorbidities on top of complex socioeconomic barriers. As a result, the highest-needs communities are incurring enormous costs to the healthcare system while still falling through the cracks.
To change the trajectory of outcomes for people at risk of major complications from diabetes, health plans need to find innovative, proactive, and culturally sensitive ways to work with these groups. It starts with small, sustainable changes including building trustworthy relationships, communicating in the member’s preferred language and channel, and offering empathy and education to people living with diabetes.
Building trust to encourage human engagement and therapy adherence
A Personalized Approach to Medication Nonadherence
At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
Many communities of color have historical reasons to mistrust the modern healthcare system, leading to lower levels of engagement and delays in addressing clinical concerns. And as The New York Times notes, many people (especially men) face additional stigmas against the “weakness” of seeking out care for seemingly minor concerns, likely contributing to the fact that men in San Antonio are three times more likely than women to experience an amputation related to complex diabetes.
Breaking through these misconceptions is key to connecting people living with diabetes with care and fostering relationships that encourage ongoing adherence to medications, self-monitoring, and collaboration with providers and health plans.
Since it’s no secret that many members avoid picking up the phone when their health plan calls, Medicaid plans should consider getting creative about leveraging partners that are already trusted within the community.
This could mean working with local religious organizations on blood sugar testing or foot check events; sponsoring a farmers market with classes about healthy swaps for traditional dishes; collaborating with social media influencers on the importance of preventive care; or working with providers, diabetes device manufacturers, and lifestyle coaching services to give members an easier on-ramp into managing their long-term health.
Creating a trusted presence that shows understanding of the community and dedication to its well-being will be the first step toward building relationships and reducing social barriers to diabetes care.
Communicating in a clear, culturally sensitive manner
Converting awareness into actionable relationships depends on clearing communication hurdles, such as reaching patients via their preferred channels and in their preferred language.
In areas like Texas, where close to 30% of residents speak Spanish at home, English-only communications are likely to be ineffective for a large number of people. Something as simple as making materials available in Spanish, as well as English, could have an outsized impact on care, as one Medicaid health plan serving multiple regions of Texas, including El Paso, quickly found out.
After introducing Spanish language text messages, it took less than a year for hundreds of members to proactively reach out to clinical staff in their preferred language looking for support and insights specific to managing complications from diabetes.
For another plan serving a highly culturally diverse population in the Northeast that speaks more than 20 primary languages, a language line offering a wide array of interpreters helped ensure that members could communicate freely with outreach staff from a diabetes remote monitoring device partner. The health plan prioritized collecting data on preferred languages up front to ensure that the right interpreter would be available to assist with building trust and improving engagement to boost outcomes over time.
Educating with empathy to foster long-term relationships
Once members are aware of the need for diabetes-centered care and open to engaging in the process, plans must provide actionable education, coaching, and services to prevent complications.
Whether coming directly from a plan or from a partner, these interactions must be tailored to the needs of each individual and acknowledge the fact that not all members have the capacity or resources to stay on track with their care.
In addition to using population health analytics to identify targeted socioeconomic vulnerabilities, plans can employ motivational interviewing techniques to establish a member’s baseline abilities to access and adhere to care.
Working with an interpreter or on their own, outreach staff should ask open-ended questions about the member’s challenges, intrinsic motivations, and goals. These questions may reveal whether a member is feeling overwhelmed by their many health issues and is in need of extensive assistance or if they are frustrated by a specific barrier that can be easily addressed with an existing plan benefit.
During these interactions, no matter how long they take, outreach staff should strive to make members feel like their top priority via active listening, empathy, and a collaborative approach to problem solving.
In Texas and elsewhere in the country, meeting members where they are in their healthcare journey is essential for keeping lines of communication open and creating the right conditions for people to proactively seek out diabetes care. By employing culturally sensitive care and communications techniques and prioritizing the individuality of their members, health plans can effectively break down barriers and connect all people with the tools they need to live healthier, longer lives free of the complications of unmanaged diabetes.
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Elizabeth Hamacher is the Vice President of Care Management at Podimetrics. Elizabeth has held clinical leadership roles at Consumer Medical, Beth Israel Lahey Health, Coastal Medical, Cape Cod Healthcare Physician Hospital Organization, and Emerald Physician Services LLC, leading strategic planning, leadership development, operations, and quality improvement efforts. She holds a Master's degree in Healthcare Leadership from Brown University, a Bachelor of Science in nursing from Massachusetts General Hospital Institute of Health Professions, and a Bachelor of Science in Mathematical Sciences from Worcester Polytechnic Institute.
