In this section, we provide resources that can support the development of an inclusive environment to meet the diverse needs of all people with diabetes. Creating an inclusive environment for care is critical to reducing disparities in diabetes outcomes among Medicaid beneficiaries through our collaborative. Topics include a framework for integrating health disparities into quality improvement (Resource F1.1), screening and referral for addressing social drivers of health (Resources F2.1-F2.5), and inclusive resources for diverse populations (Resources F3.1-F3.2).
Dashboard Data Measure: % of adults with diabetes and A1C ≥ 9 screened for social needs in the last year.
It is essential that we work to improve diabetes quality outcomes, such as A1C, for all patients. Creating an inclusive environment of care through prioritizing measurement of disparities and interventions designed to address the causes of those disparities is also critically important. Social drivers of health (SDOH), and lack of inclusion, contribute strongly to disparities in diabetes outcomes.64-66
F1: Health Disparities Framework
To address persistent disparities in health outcomes, practices can use practical frameworks to design and implement interventions that promote inclusive care. The PETAL framework provides a structure for integrating inclusion and disparities-focused approaches into a learning health system.67 The framework includes real-world examples to help practices build infrastructure, identify and address disparities, and create more inclusive care environments
F1.1: Using the PETAL Framework
Cardi-OH’s Capsule provides information on the PETAL framework that can be applied
to a learning health system or quality improvement efforts and provides examples of
how to apply an disparities framework to a QI project in primary care.
F2: Identifying and Addressing Health-Related Social Needs
We know that 80%-90% of the modifiable factors contributing to health are related to social, environmental, and structural context.68 These factors, referred to as the social drivers of health, often contribute to the root causes of health outcome disparities in diabetes64 and screening for and addressing social needs is one potential pathway to reducing diabetes disparities. The resources below include validated tools to screen for social needs in the primary care setting, as well as resources around referral to social care providers for patients who screen positive for social needs and desire assistance connecting to resources.
F2.1: Example Process Map for Social Drivers of Health (SDOH)
F2.2: Summary of Social Needs Screening Tools
This Cardi-OH resource provides a list of tools used in primary care settings to screen
for social needs and shares lessons learned from the implementation of social needs
screening.
F2.3: Ohio Network of Certified Pathways Community HUBs
This document provides contact information for your primary care practice to connect
with a Pathway HUB within your area of Ohio. Pathway HUBs assign a community health
worker to work with a client to address their health-related social needs. See map.
F2.5: The EveryONE Project Assessment and Action
American Academy of Family Physicians has additional resources for identifying and
addressing social drivers of health exist on their website.
F2.4: Community Resource Links
There are multiple sites that provide resources available to assist providers in finding community resources for patients to address health-related social needs including:
United Way 211
Get assistance for your social service needs 24 hours a day.
Findhelp.org
Financial assistance, food pantries, medical care, and other free or reduced-cost help.
Unite Ohio
A coordinated care network to connect to much-needed wraparound supportive services.
F2: High-Reliability Intervention Insights
Intervention: Implement a standardized workflow to screen for SDOH and connect patients with timely internal and community-based resources. Comprehensive screening should include transportation, food insecurity, housing instability, and communication barriers that may affect engagement in care.
Practice Examples: Participating practices embedded SDOH screening into routine care using standardized workflows that included:
These coordinated workflows helped ensure patients were connected with appropriate resources in a timely and consistent manner.
Reliability and Sustainability: This intervention strengthens reliability by:
Practices found that SDOH screening was most sustainable when identified needs could be addressed through established referral pathways and readily available resources. Standardized workflows helped ensure patients consistently received the support needed to improve engagement in care and health outcomes.
F3: Resources for Diverse Populations
The resources listed below are designed to offer essential services to everyone with diabetes. As many individuals with diabetes face complications that make it difficult to engage in physical exercise, we have also included a resource aimed at helping these individuals achieve their exercise goals to improve their diabetes management. Please reach out to your Quality Improvement Coach if other resources are needed to better serve your patient population.
F3.1: National Culturally and Linguistically Appropriate Services (CLAS) Standards
These are a set of 15 action steps intended to promote health outcomes, improve
quality, and help eliminate health care disparities by providing a blueprint for individuals
and health and health care organizations to implement culturally and linguistically
appropriate services.
F3.2: Increasing Physical Activity and Exercise in Adults with Disabilities
This Cardi-OH resource details special considerations and recommendations for
physical activity for adults with disabilities.