Those who work with people with diabetes know that there are significant disparities in diabetes outcomes influenced by social drivers of health. To address these issues, health systems need to engage with disadvantaged communities and address community needs. On this episode of The Huddle, Drs. Marshall Chin and Monica Peek, internal medicine physicians at the University of Chicago, discuss a national initiative to address health disparities in diabetes care called Bridging the Gap.
To learn more about this initiative, visit bridgingthegapdiabetes.org
For more information on the project, read this Journal of General Internal Medicine article: Integrating Medical and Social Care to Reduce Diabetes Inequities: Lessons from the Bridging the Gap Program | SpringerLink
Kirsten:
Hello and welcome to ADCES's podcast, The Huddle: Conversations with the Diabetes Care Team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm Kirsten Yale, Director for Research at the Association of Diabetes Care and Education Specialists. Today we are joined by Dr. Monica Peek, and Dr. Marshall Chin, both internal medicine physicians at the University of Chicago. Dr. Chin and Dr. Peek are recognized globally for their work in population health, specifically addressing social drivers of health. They're talking with us today about Bridging the Gap, a national initiative to address health disparities in diabetes care. We are so excited to have this conversation with Drs. Chin and Peek, and hear how the Diabetes Care and Education Specialist can support people in marginalized groups living with diabetes. Welcome Monica and Marshall.
Monica Peek:
Thank you so much, we're delighted to be here.
Marshall Chin:
Welcome, Kirsten.
Kirsten:
So I've been a big fan of your work for many years now. You guys have done so much work in building partnerships with communities, reframing the care team, and really transforming how care is organized. And so much of your work has sparked really these essential conversations we need in healthcare to make us rethink and probably reassess too, how we're delivering care. And so truly honored to have you on The Huddle for this conversation. And would love if you could introduce yourselves to our listeners, just because I know your work, but I would love for our listeners to hear a little bit more about your passion, what drives you, and really what brought you here.
Monica Peek:
Great. My name is Monica Peek. I'm an internist, so a primary care physician. I see patients at the University of Chicago, which is located on the south side of the city. Most of my patients are working class, African American patients who have diabetes and a range of other chronic medical conditions. I'm also a bioethicist, a health services researcher. And my passion is really social justice and health equity. And so even if I wasn't a doctor, I would be trying to figure out how to get an equal society. If I was a carpenter or whatever I was, I would be trying to figure out how to make the world a more just and equal place. And so thankfully with the skills that I have as a clinician and a researcher, I can do that in the healthcare space. And thankfully with where we are now in our time and space and place in this country, I'm able to think more broadly about what that means for our patients and community and think outside of the healthcare walls when it comes to how to achieve health for people.
Kirsten:
I love that you said that, that even if you weren't a physician, because all of those perspectives that you bring, I mean, very broad and incredible either way, but any of us can do that, right?
Monica Peek:
Exactly. We all have to.
Kirsten:
Yeah, we all have our place, right? So Marshall, before we get in, maybe you can introduce yourself too.
Marshall Chin:
Well, hi Kirsten and thanks for inviting us. So I'm Marshall Chin. I'm a general internist and a health service researcher also at the University of Chicago. I'm third generation Chinese American. So my grandparents came over to the US in the early 20th century. And my mom and dad, they grew up in Boston, Chinatown, both parts of large families. My dad's side was mostly laundry. So most of my uncles were these blue-collar guys who worked in the laundries. And my mom's side of the family was noodles. And as a kid, we would go into Chinatown every Saturday to see the extended family. And I think like as a kid, just sort of seeing upfront then some of the social and economic challenges that the folks in Chinatown had, as well as this bamboo ceiling that, you know, my aunts and uncles were very talented, bright people, but there was a limit in what they could do because of the discrimination of that era and all. So equity issues had always stuck with me. And then when I started medical training, I was a student at the university of California, San Francisco. I did most of my rotations at the county hospital, San Francisco general hospital and the VA system. And so anyone training in healthcare sees upfront, you know, from day one, the various inequities and disparities. And so really that's been a passion for a long period of time. And so like Monica, I've been working on interventions at the individual organizational community and policy levels now for a long time to try to advance health equity so that everyone has a fair and just opportunity to maximize their health potential.
Kirsten:
Yeah, I love that experience and background because sometimes that something personal like that can drive us so much. And tell us about bridging the gap. which is really does like bring all of your passion into one project, right?
Monica Peek:
It's super exciting. It's really been an honor to have this program for the past five years. We're actually sunsetting that program this month. And what it has been is an initiative funded by the Merck Foundation to bring together medical and by medical we mean healthcare and public health organizations with non-medical organizations. So in food delivery and legal systems and other kinds of things that impact health to try and improve the health of people who have diabetes, mainly communities that are disproportionately affected by diabetes and have worse outcomes. And so we've had eight sites throughout the country who've been working on these problems, thinking about how to innovatively think about their own healthcare systems, how to integrate medical and social care, how to partner with their community-based organizations and thinking about how to best deliver care to some of our most marginalized patients who have a lot of complex medical and social needs but need the best care possible.
Kirsten:
So we've talked a little bit about how patient care is fractured. And I love how you address this. So often we hear in the academic medical center about the intersection of public health and medicine. But what you're really bringing in is this community aspect. You call it that non-medical piece. Do you think that is the puzzle piece to this fractured system, or at least a step towards it?
Marshall Chin:
Well, bridging the gap, it recognizes that there needs to be state of the art care regarding how we provide population health management for diabetes patients. And part of that involves addressing the medical and social. So for example, all of our eight grantees had state of the art primary care. So things like empanelment where every patient was assigned to a regular care team, team-based care, which involves then nurse, clinician, educator, often community health worker, to help bridge that gap between healthcare system and community. And then a very cognizant recognition that we need to address social drivers of health, both the issues that confront an individual patient. So for example, right now, there's a lot of interest in screening individual patients for health-related social needs like homelessness or food insecurity. At the same time, it's critical to partner for healthcare to partner with community-based organizations to address the larger structural social drivers. So the general problem of homelessness in a community or the problem of food insecurity in a community. So that two-pronged approach. And the final thing that we did that was critical was that this all is moot in terms of sustainability unless there is a business case, a financial model. So we worked with all eight of our grantees from the beginning to help them partner with their payers and funders to think about sustainable models of funding for these efforts.
Kirsten:
So I know we've talked about the lack of efficiency and policy in healthcare. I know that's what this project addresses. One of my big questions is, we always like people to walk away from this podcast with something actionable, right? And so can you describe, how did your work impact policy locally? And then what do you envision as the bigger picture of impacting policy maybe statewide, nationally, internationally maybe?
Monica Peek:
That's a great question. Because there's always policy with a little p, policy with a big P. And so we have several examples. So we can think about how policy is occurring within the context of an individual hospital. So one of our sites was a site, Providence, that was part of a multi-state integrated health system. And they were starting the process of screening for health-related social needs, which is challenging if you are gonna think just about diabetes patients or just about these kinds of patients. And what they did over time was move to universal screening and scaled that out to many of their clinics. And so when they looked back on it, they said one of the most important things in their survey that they thought was true to their mission was to do that screening for health-related social needs. So that became sort of part of the infrastructure as a little p policy of looking at all other patients who come through their doors and screen them for what they might need unrelated to direct medical care. Then you can think about policy as far as like payers. And so we had sites in Kentucky and West Virginia that were working to think about how to work with Medicaid to work on their reimbursement mechanisms to make it more sustainable and financially feasible as far as cost savings. There's always sort of the wrong pocket issue. The people who are working to save the money may not be people who actually get those savings. And so how can primary care clinics work with the payers to have some of the savings reinvested in primary care? And then there are sort of larger federal policy that we can see, we know that a lot of the things that happen at the state level are pilot sort of testing grounds for policy that we can hope to see at the federal level. And so as we're seeing more and more pilot projects and demonstration projects and people who are making the business case, like in Maryland where we saw significant reductions in hospitalizations and ED utilization, et cetera. We can then say, hey, payers at large, national health insurance, Medicare, let's continue to invest in payment models that support this kind of work. Let's continue to invest specifically in the kind of reimbursement for navigators, community health workers, diabetes educators, parts of the care team that are critical, that may be underfunded, and that can specifically address the behavioral needs, the social needs that patients who have diabetes have, but really have not been fully and comprehensively financially supported and reimbursed.
Marshall Chin:
I'll add a couple of points to Monica's excellent explanation. Ultimately, every healthcare professional and healthcare delivery organization needs to undertake their own journey and create their own story. One of the strengths of Bridging the Gap was that we had eight different grantees, very different: urban, rural, frontier, small, large, different patient populations. And so it became clear that there may be some general principles. At the same time, each grantee had to individualize and tailor to their particular context. And all your listeners will need to do the same. That they're, you know, you're not starting from scratch. That there is sitting on literature and evidence-based and all and principles. That's a helpful starting point. At the same time, again, it has to be tailored for the particular setting. Having said that, a critical point that Monica made was that it all has to fit together as a system. So something like diabetes care, which we know from the beginning is complex, both what are the barriers to good effective diabetes care and outcomes and the solutions, the medical and the social and behavioral, et cetera, is complex and the whole system has to fit together. So, it is this combination of everyone has to do their thing, but from policy perspective, both public policy and then individual organizational policy, it has to fit together. And I think that's one of the overall lessons from our program that we've come up with a variety of different lessons at those two levels that could make it, in many ways, comes down to like how do you create a system that aligns so that it's in everyone's interest to do the right thing? Because every clinician knows that, if we could really address our medical and social needs of our patients, we'd lead to better outcomes. That's not what the system or the payment system supports or incentivizes, but it can be done.
Kirsten:
And that's what we all want to do, right? Is do the right thing. And Monica, I interrupted you, so...
Monica Peek:
Oh, I was just going to say that I know that many people in the audience are diabetes educators and that one of the critical roles that all of our teams had were diabetes educators. And for many systems, for a single physician, clinic or practice, that is a luxury. But for people who have diabetes, and particularly for people who are struggling with diabetes management, the diabetes educator can be life transforming as far as self-management, learning what's in the community, all of those things, and is really critical to this healthcare team, this team-based care that we're talking about. And so the idea of having an entire wraparound team is not new, but is one that everyone needs to sort of really get on board with. And the idea of expanding that team even further to really at the very minimum include, you know, behavioral interventionists, to include those social bridges, people who can be in the community and in the health care system and reach people where they're at, help bring them into the health care system. And so there's, again, space for everyone with all of their skills to be doing this work to drive equity.
Marshall Chin:
And Kirsten, I'd like to build upon Monica's point and get back to the nature of your original question was what can diabetes educators, clinicians do in this space? And I think that diabetes educators, clinicians have a lot of power and legitimacy taking care of patients and that's like our prime job. And so that's clearly like the main job. Same time, there is this knowledge, expertise, and again, legitimacy and power that we have because of that role. And some of the wider policy work, again, little p and big P policy work, really requires partnerships and coalitions. It is a thorny problem that requires a variety of expertise. So some things that folks can do are first, advocating for their patients to make sure that patients are at the table as we create these systems and policies. It's one thing to say, well, we're patient-centered. It's another thing to really have the patients at the table. And then clinicians can be great at sort of advocating and having patients at the table. Some of it would be then collaborating with like the systems people, the quality improvement people, as you're thinking about, well, how do you redesign the system to be better in terms of the team-based care and to really tailor to meet the needs of patients. Some of it involves partnering then with like the business people, the policy people, the financial people to sort of brainstorm through, well, given their expertise in finance and policy and our expertise in terms of clinical medicine, how do you combine that knowledge to come up then with...in some ways the mantra is payment systems that support and incentivize the types of care systems that address a patient's medical and social needs to advance health equity. So it is sort of a sequential approach. It's not paying for payment sake, but it's gotta be to support those care systems that again, frontline clinicians, educators know are necessary then to lead to the best outcomes.
Monica Peek:
One of the things I realized that we hadn't really discussed is why addressing social needs is important in the first place for people who have diabetes and to make sure that we've level set in for that. And I would say that there are two reasons. One is that when our patients come to us and they don't have stable housing, they're not sure where their next meal is gonna come from, they have a relative that's in the prison industrial complex, they themselves are experiencing violence. Their priorities are not around their immediate health needs. They are around these immediate material and interpersonal needs. And so as a health system, we have to be invested in making sure that people have their basic human needs met so they can then be free to address their urgent and preventive health needs. In addition, we know that things like food insecurity are related to worse diabetes health outcomes. You're either eating to save calories and then your hyperglycemic can get admitted or you're going without food and you're hypoglycemic and then admitted. And there are so many different kinds of social determinants of health that have been associated with poor health outcomes. Even things like associations between exposure to community violence and hypertension. You know, so things just, you know, the stress of that. And so there are direct connections that medically we want to be invested in. So when someone comes in with chest pain and a heart attack, in addition to thinking, hmm, are they on the stat? And we might be thinking, hmm, are they coming from a neighborhood with lots of community violence? We, so we need to make sure that people have the freedom in their life to address their health needs because these other social needs are not an issue and we need to know that these social needs are not exacerbating or causing the health problems in the first place.
Kirsten:
So I wrote down a million notes as you were talking. And I think the big thing I can ask for our listeners, so this is complex, right?
Monica Peek:
It is.
Kirsten:
Very complex, even just listening to you talk through it so eloquently. When I think about the little p and the big P, it makes me think about small wins create big change. You all are talking to the choir probably with,
Monica Peek:
Yes.
Kirsten:
the DCES is it's really been front and center with partnering with community health workers, knowing that really that's the way to make change. And that's what our members want to do. Sometimes not so easy when you're in a big practice, right?
Monica Peek:
No, it's not.
Kirsten:
AY'know I've heard of incentivizing to do the right thing, which can make these big changes, you know, would there be two or three maybe examples or ideas that you could give our listeners to say that these are the reasons why. These are the points you can bring to your health system to say like, this is why we need to do this. Or maybe a small change that they could make with the reasoning behind it.
Marshall Chin:
I'll start with a couple of points we haven't mentioned yet. So one is that the solutions have to address the causes of the problems. So in other words, that if we're looking at why some patients aren't doing well, or why there's disparities in outcomes between a more and less advanced population, we need to do so-called root cause analysis, which involves in particular talking with the patients, the communities, and then the frontline clinicians, educators, and staff. Why is this occurring? And then the solution has to then be matched to that particular problem. The solutions that actually work for proving care and outcomes and reducing disparities are those interventions that holistically address a patients' social and medical needs that involves a close and ongoing relationship with patients. So in some ways, it's the principles of primary care, ongoing good team-based care, holistic care, biopsychosocial model, all the stuff we've been taught but which the system is not designed to do. So that's just one sort of point there. A second point too that we haven't raised before is that there's a lot of interest now by healthcare systems regarding worker wellbeing and burnou, both because again, it's the right thing to create an environment which people don't burn out, as well as from an economic standpoint, is very expensive for organizations with turnover. And when they lose someone, they have to hire a new person and all of that. And when you look at the data, one thing that causes burnout is when educators, providers, clinicians feel they have no control or not enough control over what they do or what drives the patient's outcomes out of their control.
Kirsten:
Yeah, that was probably one of the, at least for me, one of the most usable answers I have heard to date. I will say, it just reminds me that, seems like these days in the health system that we really look at these changes that have a big impact in the short term. And I think that there's many reasons for this. But diabetes is long-term, right? And it has a big impact on our communities and our health system, but it's not just a five-year turnover, right? It's going to be a lifelong issue for us to deal with. So those examples you gave, I think, are ones that can address the long-term inadvertently or kind of in an indirect way by hitting those shorter five-year goals that systems want to hear, and so really usable. I'd love if there's any final thoughts you wanna share with our listeners, any final thoughts to leave them or inspire them.
Monica Peek:
Yeah, I think this is a really exciting time for people who are interested in equity and for people who are interested in having their patients, you know, live their best lives. That we are getting the support from payers and from government and testing out new and different models that I think we can really actually push the envelope really far in the next few years. And so I'm really hopeful about our potential.
Marshall Chin:
And again, I build upon Monica's point that we are in a window of opportunity that with some of the broader societal issues we've seen regarding the gross inequities from COVID-19 impact on different populations, and then police brutality and George Floyd, there's much more public awareness of structural racism, structural inequities, and various systems that lead to these inequities. And within that part of the challenge and opportunity is having these honest discussions. And we just sort of started here, but when it comes down to it, there are these tough discussions that need to occur regarding relationships, systems of power, privilege, why systems have been set up in a way that make it hard, for example, for various marginalized populations, the poor, certain I think, minoritized groups to do well with their health and diabetes outcomes. I think it's all the concrete things we mentioned and then having that dialogue regarding these tough issues. And this is a great time, this is the window of opportunity for us to make a lot of progress. And I'm very optimistic regarding making progress on all these health equity issues.
Kirsten:
Yeah, I appreciate that I heard you both say opportunity and potential because I do think with everything that's happened in the recent past few years, we really are at that place where it's a tipping point, right?
Monica Peek:
Yes.
Kirsten:
And we can recognize it and dive in. And I can tell you just because I have the opportunity to talk to diabetes care and education specialists every day. It's why I'm here. It's why I've stayed here for so long. And I can tell you that this is the right group to make that difference and partnership with many others. So really, really appreciate you joining today.
Monica Peek:
Thank you so much for having us.
Marshall Chin:
Thank you very much, Kirsten.
Kirsten:
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes at diabeteseducator.org/podcast. And remember, being an ADCES member gets you the access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at diabeteseducator.org/join. The information in this podcast is for informational purposes only. It may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.