Diabetes care starts with addressing factors outside the clinic
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Susan Weiner, MS, RDN, CDCES, FADCES, talks with Jasmine Gonzalvo, PharmD, BCPS, BC-ADM, CDCES, about the interrelations between social determinants of health and diabetes and the role of community health workers and pharmacists, among others, in addressing factors outside the diabetes clinic.
Weiner: We’ve seen greater awareness in the past few years about how nonmedical conditions affect health. Why now, and what are some examples of important social determinants of health in diabetes?
Gonzalvo: For decades now, health systems and primary care, in particular, have been helping people with diabetes “put out fires,” trying to keep people out of the hospital, decrease risks for complications, and provide self-management education and resources following a diagnosis and subsequent progression of diabetes. In an effort to move away from this downstream-focused approach, in more recent years, more attention has been given to prevention of type 2 diabetes and the upstream factors that contribute to this diagnosis.
Many of the upstream factors relate to the social and political determinants of health, which have broad implications for diabetes. For example, we know that there is an inverse relationship between education level and diabetes prevalence. We also know that policy and legislation relevant to diabetes have a significant impact on diabetes outcomes. The pharmacological and technological spaces in diabetes have significantly advanced in recent years. Relevant policies can either promote or limit access to newer medications or devices with serious implications to the diabetes community. Awareness, education, advocacy and action in the social and political determinants of health are essential to optimizing care for all people with diabetes.
Weiner: Where does mental health factor into an assessment of social determinants of health for people with diabetes in underserved communities?
Gonzalvo: The allostatic overload that individuals from underserved communities may endure from generational poverty, adverse childhood experiences and trauma, unemployment, systemic racism and other hardships has a significant impact on mental health. One common tendency that must be avoided is to fix mental health before optimizing diabetes management. This tendency can exacerbate clinical inertia and contribute to negative clinical consequences. Referral to mental health services may be appropriate for some individuals, although access may be limited for some communities. Diabetes care teams can perform a variety of mental health assessments to evaluate strategies for management or subsequent referral.
Weiner: The 2023 updates to the American Diabetes Association Standards of Care recommended working with community health workers to support diabetes care and reduce cardiovascular risks in underserved communities. How might that work?
Gonzalvo: A strong evidence base demonstrates that community health workers play an integral role in improving overall health for communities that are underserved. As awareness, education and funding have grown, states are implementing community health workforces to help optimize care for communities, including for people with diabetes. Some examples of community health worker responsibilities may be overcoming transportation barriers by helping people to schedule rides through Medicaid to take them to appointments or to pick up their medicine from the pharmacy, performing social determinants of health risk assessments, conducting home visits and assessments, assisting with insurance enrollment and referring to helpful community resources.
Greater awareness, knowledge of and experience with community health workers is necessary within health systems, community-based organizations, pharmacies, schools and other employment settings to realize the full impact of community health work efforts. The community health workforce will continue to play an essential role in improving health for underserved communities. Sustainable funding models must be developed to maintain this critical workforce, while also ensuring that community health workers are provided a livable wage, at a minimum.
Weiner: How can pharmacists, in particular, help address social determinants of health in diabetes?
Gonzalvo: Multiple approaches can be taken by pharmacists to help address social determinants of health for people with diabetes. Pharmacists are increasingly expanding their roles to improve outcomes at a population health level, serving as health equity advocates in communities that are underserved, developing health education policies and programs and collaborating with other disciplines to mitigate health disparities.
Community pharmacists are easily accessible in most communities and can connect people with diabetes to local resources, facilitate care coordination, offer insight on insurance coverage to improve access to medications, and provide education. Pharmacists are well positioned in many communities to implement diabetes screenings or to provide diabetes self-management education and support. Pharmacists are also working alongside other clinicians in a clinic setting, performing medication management, facilitating prior authorization approvals and advancing policies that optimize medication access at a population level in facilities serving communities facing barriers related to the social and political determinants of health. Pharmacy technicians are also being trained as community health workers — a role that has robust evidence in improving diabetes care and outcomes, as previously mentioned.
Greater awareness and acceptance of pharmacists’ and pharmacy technicians’ ability to address barriers among the general population and across medical settings could broaden the capacity to mitigate health disparities for people with diabetes.
For more information:
Jasmine Gonzalvo, PharmD, BCPS, BC-ADM, CDCES, is director for the Center for Health Equity and Innovation and clinical professor of pharmacy practice at Purdue University College of Pharmacy. She can be reached at jgonzalv@purdue.edu.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
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