At this weekend's annual American Diabetes Association conference, putting this model into action was the topic of a session geared at CDEs and program administrators, where four patient-care experts shared their experiences from communities around the country. Two full hours worth of details on improving patient record-keeping, meeting national standards, and making services more accessible to patients, especially the truly needy and uninsured -- and here's the quote that stuck in my mind:

"Every drop in A1c levels translates to cost-savings for the system."

Yet, the system doesn't clearly understand this. Or at least it isn't always acted upon, the presenters said.

These providers are all working hard to demonstrate the fact that diabetes is — especially in the poorest neighborhoods and nations — largely a community problem, and needs to be treated and funded as such.

Caregiver and Patient Obstacles

Linda Siminerio, an RN/CDE from Texas explained, obtaining funding for thorough, well-organized preventative care is an ongoing struggle -- one that eats up professionals' time with paperwork such as exhaustive funding applications -- rather than spending more time actually seeing and helping patients. Meanwhile, providers are doing their best to figure out the barriers on the patient side, i.e. what keeps so many patients from coming in regularly for the care they need? Not surprisingly, it was logistics, convenience, and money.

Nowhere is this more apparent than in sprawling Los Angeles County, explained Dr. Anne Peters, director of endocrinology programs at USC, who described a comprehensive program she spearheaded for helping the neediest patients there. LA County covers over 4,000 square miles and has the largest population of any county in US, making it more populous than all but 8 states. Forty-five percent of this is made up of Latinos, an especially high-risk group, and that number is expected to rise to 60% by next year. LA County also has the highest percentage of uninsured people - 3 million without insurance - and the highest death rates from cardiovascular disease.

The LA County program quickly discovered some core problems: the medical system was so overloaded that patient appointments were made 9 months in advance, resulting in an extremely high no-show rate; those who did show up often had to give up their daily wages to do so; fast food was readily available (61% of local restaurants were fast-food chains); the neighborhood was unsafe for walking or exercising; and patients lacked both knowledge about diabetes and often also access to a nearby clinic for treatment.

The "community-based intervention program" set in motion last year in East and South LA included development of farmer's markets and community gardens and improving school meals. Community clinics were supported or erected where patients could get quick on-site testing for A1c, blood pressure, and lipids and immediately discuss the meaning of these results with an educator. Follow-up studies show that community (and therefore individual) behavior did change, through "community assessment, engagement and participation."

Community Therapy

What all this tells us about "The Changing Face of Diabetes Care" (title of the ADA session) is that the Chronic Care Model can be highly effective. The trick is to adequately address community needs on a number of levels, including:

1. Creating a culture, organization and mechanisms that promote safe, high-quality care
2. Delivering effective, efficient clinical care and self-management support by organizing and motivating care teams
3. Organizing patient and population data to facilitate this efficient and effective care
4. Mobilizing community resources to meet the needs of patients