Exploring what works to improve diabetes care and outcomes for people with complex needs

The challenge

When people live with diabetes that’s not well controlled, it can put them at risk for life-altering long-term complications, including heart disease, kidney disease, eye and vision problems, nerve damage, and more. The reasons that people have a hard time controlling their blood sugar are varied and often include contributing factors — such as having unmet medical, behavioral, and social needs.

Community health centers and other health systems face many challenges when trying to meet those needs because it can be hard to match patients with the right level of care. Given these challenges, how can we build scalable and effective programs that work across diverse health care settings and are tailored to meet the needs of people with diabetes who need the most support?

To help find potential solutions, the ACT Center is working with Vayu Health, a nonprofit startup in California, to design a program to support people who are living with diabetes that’s not well controlled. The Vayu program serves people who have insurance through Medicaid and focuses on partnering with primary care providers at federally qualified health centers (FQHCs) to provide extra support for people with unmet medical, behavioral, and social needs. This support is provided by an integrated team that includes a community health worker, certified diabetes care and education specialist, behavioral health therapist, and registered nurse.

The work

Tapping into our experience with program design and implementation, patient engagement, and social health, the ACT Center is supporting the development of the Vayu program by:

• Facilitating the development of a training program for new Vayu staff
• Creating a communications plan and supporting materials for spreading to additional clinics
• Providing technical assistance throughout the design, scale, and spread phases of the project
• Designing and carrying out an independent process evaluation to assess facilitators and barriers to scale-up and spread

What we’re learning

So far, Vayu has piloted its program with 51 participants at 1 FQHC, and results from that pilot were recently shared in a paper published in The Permanente Journal and in a case study for the California Health Care Foundation. From the pilot, we observed that Vayu enrollees had high levels of complex, unmet medical, behavioral, and social needs. For example:

• 83% of Vayu participants had at least one behavioral health condition, such as depression, anxiety disorder, or substance use disorder.
• More than half (51%) reported living with depression, a rate that is 4 to 5 times higher than that in the larger population of people with diabetes.
• More than half also reported adverse childhood experiences, and more than 90% reported at least one unmet social need, such as insecurity around food, housing, or employment.

We also found that the average monthly A1c among Vayu program participants was lower than that of the comparison group. When Vayu began enrolling participants, A1c values were higher for Hispanic participants than non-Hispanic white participants. Over the 12 months of the pilot, that disparity declined and was no longer present at the end of the pilot. Vayu’s clinical team attributed these findings to their work to prioritize addressing participant-identified goals, building trust, and enhancing access to support to manage their diabetes and behavioral and social health needs.

Impact

Collaborating with Vayu, our ACT Center team has created an assessment to help determine if a clinic is ready to become a partner in the program, a clinical staff training framework, and tools for tracking quality improvement data. Using data collected from interviews with Vayu staff and partners, we have also highlighted obstacles that might prevent the program from reaching its full potential — such as staff at participating clinics not being aware of the initiative or participants being reluctant to use the behavioral health services of the program.

Next, Vayu will expand its program by partnering with 2 additional FQHCs, hoping to enroll 150 to 200 people into the program across the clinics in 2024. The ACT Center will continue working with Vayu through most of 2025 to design and carry out a process evaluation to help them understand how the program is being implemented at the new clinics. The evaluation will include interviews with clinical staff and patients who have participated in the program so Vayu can learn their perspectives to inform the future of the program.

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Featured publications

Parchman ML, Stefanik-Guizlo K, Penfold RB, Holden E, Shah AC. Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs. Perm J. 2023 Dec 20:1-6. doi: 10.7812/TPP/23.106. Online ahead of print. Full text

Parchman ML, Stefanik-Guizlo K, Shah AC, Glaseroff A, Holden E, Bertko J, Zúñiga R. How to Identify and Support Emerging Risk Medi-Cal Members with Complex Social and Behavioral Needs: A Diabetes Case Study. California Health Care Foundation. December 2023. Full text