Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs.

Area of Science:

• Health Services Research
• Chronic Disease Management
• Health Equity

Background:

• Medicaid managed care enrollees with diabetes often present with multifaceted health and social challenges.
• Effective interventions require integrated approaches to address these complex needs.

Purpose of the Study:

• To evaluate a program designed to partner with primary care teams to improve diabetes control in high-need Medicaid patients.
• To assess the impact of addressing behavioral health and social needs on glycemic control.

Main Methods:

• A 12-month program enrolled individuals with A1c >9% in a multidisciplinary team approach.
• Patient-led action plans, community resource linkage, and behavior change support were implemented.
• Glycemic control (A1c) was tracked monthly for participants and a comparison group.

Main Results:

• Participants experienced a significant average monthly A1c reduction of 0.699 compared to the control group (P = .0008).
• High prevalence of behavioral health conditions (83%) and unmet social needs (>90%) was observed.
• The program reduced the disparity in A1c control between Hispanic and non-Hispanic White participants.

Conclusions:

• Addressing complex medical, behavioral, and social needs can lead to rapid and sustained improvements in diabetes control.
• External programs partnering with primary care teams can enhance clinical outcomes for vulnerable populations.
• The intervention demonstrated effectiveness in improving A1c and reducing health disparities.