We’re working to improve health outcomes and decrease health disparities for vulnerable and underserved populations with type 2 diabetes in the United States. This population is more likely to have diabetes and often experience barriers to effectively manage the disease. We aim to increase access to care and build sustainable partnerships between health care and non-health care sectors.

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ESTIMATED PEOPLE IN THE U.S. WITH DIABETES

Bridging the Gap program partners are implementing comprehensive, evidence-based programs to address the many factors that influence health, such as access to nutritious foods, options for physical activity, housing, and legal services. This collaborative approach between both health care and non-health care sectors focuses on improving medical care, and addresses the social and environmental factors that affect vulnerable populations.

Learn about the partners and their programs

 

 

 

 

 

 

 

Many Factors Play a Role in Diabetes-Related Health6

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Patients with diabetes who are food insecure may go hungry, reduce food intake, or rely on energy-dense, inexpensive carbohydrates when they cannot obtain affordable food.

Food-insecure patients with diabetes are more likely to be at risk of hypoglycemia, have poor glycemic control, and have diabetes-related hospitalizations.

All Bridging the Gap partners recognize that food insecurity has a major impact upon the health of patients with diabetes. Learn more about their strategies to address food insecurity as part of a comprehensive approach to diabetes care.

Patients with unstable housing are more likely to experience diabetes-related emergency department visits and hospitalizations. In a national study, less than 1% of these individuals report receiving help with housing through their clinic.

The following Bridging the Gap partners work with community partners to address housing as part of the spectrum of diabetes care:

Patients with unmet material needs encounter difficulties paying for medications, medical equipment, food, and utilities. These patients may underutilize medication due to cost and may experience higher rates of hospitalizations and poor diabetes control.

Health care teams in Bridging the Gap are working to understand their patients’ daily life circumstances and link patients to specific resources to address material needs and support self-management.

The following Bridging the Gap partners link patients to resources for utilities, medical supplies, or medications:

Access to health care is critical to improving the health of persons with diabetes. Health care visits present opportunities for patients to receive information and tools to address their diabetes self-management needs. For vulnerable populations, definitions of “health care” and “health care workers” may need to expand to include nontraditional roles (e.g. community health workers) and institutions (e.g. healing centers) that can effectively bridge marginalized groups with traditional health care.

Bridging the Gap partners are expanding their health care teams to include roles such as community paramedics and care coordinators, to more effectively reach patients, and simultaneously address their medical and social needs.

Patients who face transportation barriers due to distance, cost, and access often miss appointments, do not receive optimal care, and have poor diabetes control.

Transportation can be a key part of helping patients maintain their access to health care and their connections to a variety of health-related services and resources.

The following Bridging the Gap partners work with community partners to address transportation as part of the spectrum of diabetes care:

Living with diabetes requires patients to navigate health care systems, make multiple lifestyle changes, and face daily self-management decisions.

Bridging the Gap partners recognize how patients benefit from the support of community health workers, promotoras, patient navigators, peer educators, and peer mentors. These individuals may offer interpretation and translation services, provide culturally appropriate health education and information, connect patients to community resources, and help patients obtain the care they need.

Diabetes self-management education (DSME) provides patients with tools to live well with diabetes, while considering their circumstances, goals, and life experiences. DSME is designed to help patients make informed decisions, learn self-care behaviors, solve problems, and collaborate with the health care team.

Learn more about clinic- and community-based diabetes self-management education being employed by Bridging the Gap partners.



Many Factors Play a Role in Diabetes-Related Health6

Click on a factor below to learn more.

Food Security

Patients with diabetes who are food insecure may go hungry, reduce food intake, or rely on energy-dense, inexpensive carbohydrates when they cannot obtain affordable food.

Food-insecure patients with diabetes are more likely to be at risk of hypoglycemia, have poor glycemic control, and have diabetes-related hospitalizations.

All Bridging the Gap partners recognize that food insecurity has a major impact upon the health of patients with diabetes. Learn more about their strategies to address food insecurity as part of a comprehensive approach to diabetes care.

Housing

Patients with unstable housing are more likely to experience diabetes-related emergency department visits and hospitalizations. In a national study, less than 1% of these individuals report receiving help with housing through their clinic.

The following Bridging the Gap partners work with community partners to address housing as part of the spectrum of diabetes care:

Health Care

Access to health care is critical to improving the health of persons with diabetes. Health care visits present opportunities for patients to receive information and tools to address their diabetes self-management needs. For vulnerable populations, definitions of “health care” and “health care workers” may need to expand to include nontraditional roles (e.g. community health workers) and institutions (e.g. healing centers) that can effectively bridge marginalized groups with traditional health care.

Bridging the Gap partners are expanding their health care teams to include roles such as community paramedics and care coordinators, to more effectively reach patients, and simultaneously address their medical and social needs.

Diabetes Education

Diabetes self-management education (DSME) provides patients with tools to live well with diabetes, while considering their circumstances, goals, and life experiences. DSME is designed to help patients make informed decisions, learn self-care behaviors, solve problems, and collaborate with the health care team.

Learn more about clinic- and community-based diabetes self-management education being employed by Bridging the Gap partners.

Community Health Workers

Living with diabetes requires patients to navigate health care systems, make multiple lifestyle changes, and face daily self-management decisions.

Bridging the Gap partners recognize how patients benefit from the support of community health workers, promotoras, patient navigators, peer educators, and peer mentors. These individuals may offer interpretation and translation services, provide culturally appropriate health education and information, connect patients to community resources, and help patients obtain the care they need.

Transportation

Patients who face transportation barriers due to distance, cost, and access often miss appointments, do not receive optimal care, and have poor diabetes control.

Transportation can be a key part of helping patients maintain their access to health care and their connections to a variety of health-related services and resources.

The following Bridging the Gap partners work with community partners to address transportation as part of the spectrum of diabetes care:

Material Needs

Patients with unmet material needs encounter difficulties paying for medications, medical equipment, food, and utilities. These patients may underutilize medication due to cost and may experience higher rates of hospitalizations and poor diabetes control.

Health care teams in Bridging the Gap are working to understand their patients’ daily life circumstances and link patients to specific resources to address material needs and support self-management.

The following Bridging the Gap partners link patients to resources for utilities, medical supplies, or medications:

REFERENCES

  1. Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2017. www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed August 23, 2017.
  2. Chow EA, Foster H, Gonzalez V, McIver L. The disparate impact of diabetes on racial/ethnic minority populations. Clinical Diabetes. 2012;39(3):130-133. doi: 10.2337/diaclin.30.3.130
  3. Wing RR, Goldstein MG, Acton KJ, et al. Behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes Care.2001;24(1):117-123.
  4. National Diabetes Statistics Report 2017, Centers for Disease Control and Prevention. Accessed September 8, 2017: www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
  5. Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: Insights from Yesterday, Today, and Future Trends. Population Health Management. 2017;20(1):6-12. doi:10.1089/pop.2015.0181.
  6. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. Social determinants of health. 2016. Available at: www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed September 29, 2016.