Collaboration and Care Coordination: Two Keys to National Diabetes Month Success Stories

William Torkildsen, MD – Chairman of Valley Organized Physicians and Guest Contributor

November is National Diabetes Month. As a primary care provider (PCP), I’ve cared for a lot of people with Type 2 diabetes over the years.

Many things about diabetes care have changed since I first opened my practice. For example, we used to focus mainly on helping patients manage their blood sugar levels. That continues to be incredibly important, of course, but now we also better understand the need to simultaneously manage patients’ heart, vascular, and kidney health. Today, new approaches and medications give us better options than we had in the past.

Still, some aspects of diabetes care remain unchanged. Too many people with Type 2 diabetes or prediabetes don’t realize the importance of managing their diabetes to prevent complications. They face higher overall medical costs than people without diabetes. What’s more, this disease will always require a collaborative team of physicians, nurses, social workers, care coordinators, diabetes educators, and others working together to increase patients’ odds of success. 

Teamwork tames SDOH

It's just a fact: Managing Type 2 diabetes is multidimensional. It almost always involves lifestyle adjustments and usually impacts conditions such as high blood pressure or cholesterol. For patients like mine, who live in the southernmost part of Texas, the “typical” difficulties are often compounded by numerous social determinants of health (SDOH). My practice serves one of the most economically disadvantaged areas of the U.S., so it’s common for patients to face transportation problems, health literacy and language barriers as well as food, housing, and financial insecurity. Frankly, it can be overwhelming, especially to the many patients with multiple dietary and financial challenges.

Meeting the diverse needs of so many people truly takes a collaborative team effort. PCPs can’t do it alone, so organizations like CareAllies have become extremely valuable. They relieve the burden on providers by bringing together the right people to ensure patients receive the care they need—including addressing SDOH.

Let me give you an example. It’s the story of a 65-year-old woman whose home blood glucose readings were dangerously high—about 300-400 mg/dL. She was traveling to Mexico to buy her medicines because she didn’t think she had prescription insurance coverage. When she couldn’t travel, she went without her prescriptions.

She was referred to a CareAllies certified Diabetes Care and Education Specialist who quickly went to work. Through several phone calls, she educated the woman about her medication benefits, the importance of medication adherence, and its impact on her blood glucose. She  worked with our CareAllies pharmacist and encouraged the patient to talk with her PCP. Then, she mailed the patient a glucose meter, pill organizer, and portion plate to help her optimize her diet and medication compliance.

The result? Significant improvement! The patient now understands why her medications are so crucial. She’s grateful to get them at a price she can afford without traveling to Mexico. Because she adheres to her care plan, her home blood glucose readings have dropped by as much as 150 mg/dL.   

We need more success stories like this one. Unfortunately, this patient's challenges are all too familiar and won’t soon disappear because diabetes diagnoses continue to rise. But National Diabetes Month encourages all of us to think about ways to expand diabetes care.

We don’t have to wait for some new blockbuster diabetes drug. We can improve outcomes now by identifying and addressing SDOH barriers. It’s not easy, and it can’t be accomplished alone. However, by collaborating with diabetes educators, like those at CareAllies, we can surround our patients with the tangible support systems they need to achieve success.