Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Abstract

Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), ( 2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

Quality Improvement Intervention Using Social Prescribing at Discharge in a University Hospital in France: Quasi-Experimental Study

“…SP has not been implemented as such in France and is rolled out under other names like health navigators or health mediators. Their entry point is via a specific disease (HIV, diabetes, etc) [ 35 , 36 ] or via a category of population (lesbian, gay, bisexual, transgender, queer; Romani; etc) [ 37 ]. One of the reasons might be the structural divide between the social and health sectors in France.…”

Increasing Continuous Glucose Monitoring Use for Non-Hispanic Black and Hispanic People With Type 1 Diabetes: Results From the T1D Exchange Quality Improvement Collaborative Equity Study

“…Yet, the integration of all aspects of SDOH screening into diabetes care is possible and has been accomplished. In a recent initiative, eight organizations successfully integrated SDOH screening into diabetes care ( 26 ).…”

Multisector Collaboration vs. Social Democracy for Addressing Social Determinants of Health

“…Prominent examples of the multisector collaboration approach include the National Strategy on Hunger, Nutrition, and Health, the Centers for Medicare and Medicaid Services' Accountable Health Communities model (which served over 1 million Medicare and Medicaid beneficiaries) and subsequent models such as ACO REACH (Realizing Equity, Access, and Community Health), state-level Medicaid 1115 waiver programs, initiatives among health care organizations and private health insurers, and calls from both the Centers for Disease Control and Prevention and the National Academy of Medicine. [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] An important distinction (albeit one not always made clearly) with multisector collaboration interventions is that, although they may understand themselves as addressing social determinants of health (macro-level social conditions that affect health), they are often actually responding to 'health-related social needs' or 'social risks': individual-level experiences such as food insecurity or housing instability that can result from adverse social determinants of health. [38][39][40] If material resources and social standing are the 'fundamental' causes of health, health-related social needs can be thought of as 'superficial' or 'surface' causes of poor health.…”