Diabetes Care Coach Program Reduces Patients’ Costs, Improves Outcomes

Clinical pharmacists and nurses serve as personal coaches and augment care of traditional diabetes educators and clinicians.
Diabetes Care Team

Photo above: Richard Haas, MD, Endocrinologist (left) and Hinal Sharma, PharmD, CSP, Diabetes Clinical Care Coach (right) meet with a patient (center). (Photo by Matt Wright.)

Patients in the Diabetes Care Coach Program have frequent contact with their diabetes coach, who is a clinical pharmacist or nurse. The first participants in the program successfully lowered their A1Cs and demonstrated a reduction in diabetes-related distress by implementing behavioral, lifestyle and medication changes.

Meet Balram Santram. Diagnosed with Type 2 diabetes in his late 30s, Santram has struggled for years to manage his condition with medications and diet. Even after working with diabetes educators and care providers at the UMass Memorial Health Diabetes Center of Excellence (DCOE), he still was unable to keep his diabetes under control. Over time, he developed chronic pain in his legs and fatigue that impacted his ability to keep up with his active family, a priority for the 58-year-old grandfather of two.

According to clinicians at the DCOE in Worcester, Santram isn’t alone in struggling to manage his blood sugar. Despite receiving diabetes education, some patients continue to have a sustained A1C above 9.0%, and some high-risk individuals face consistent challenges managing diabetes on their own. Many have missed appointments with their diabetes care team — some have even stopped making future appointments. They often have comorbidities that can complicate their treatment.

And it can become extremely difficult to manage appointments, cost of medications and durable medical equipment, family and work priorities, and their health. In some cases, it is overwhelming and has a negative impact on mental health.

Role of the care coach

Enter the Care Coach Program. This collaboration between the DCOE and Shields Health Solutions — a specialty pharmacy accelerator that manages the program with DCOE oversight — provides support beyond traditional diabetes education. While enrolled in the Care Coach Program, patients have frequent in-person or telehealth visits with a diabetes-trained provider, who is also a clinical pharmacist or nurse. This provider serves as a personal coach and augments the DCOE patient care, thus building the patient’s confidence.

Coaches serve as an accessible resource for all diabetes needs and offer supplemental support, including:

  • Managing medications
    Coaches help patients with refills and medication changes made by their doctors, as well as finding financial assistance options for patients who are struggling with costs.
  • Enhancing patient engagement and adherence
    Coaches encourage patients to become more involved in their own diabetes management and to adhere to their individual care plan through frequent touchpoints
  • Managing blood sugar
    Coaches monitor individual trends and try different approaches to keep patients’ glucose levels in target range.
  • Training on diabetes technology
    Patients sometimes need support before they feel comfortable using technology, such as continuous glucose monitors.
  • Encouraging better lifestyle habits
    Coaches motivate and set goals related to exercise and nutrition plans.
  • Providing resources for mental health as needed
    Coaches are attuned to the psychological toll diabetes management can take on patients.
  • Identifying gaps
    Coaches identify social determinants of health and provide resources for patients when applicable.
  • Collaborating with the physician and diabetes educators on patient medical needs Coaches can communicate effectively with the other members of the care team to address medical concerns and medication changes in between visits.

“As diabetes care coaches, we are in a unique position to provide patients with as frequent as weekly touchpoints to help them in this crucial time period between office visits,” said Hinal Sharma, PharmD, CSP, Diabetes Clinical Care Coach, Shields Health Solutions.

Short-term goals help patient succeed

Through the program, Santram has reduced his intake of foods high in refined carbohydrates, and now manages his medications and navigates the challenges of diabetes self-management with much greater success. After years of blood sugar levels in the 300s and 400s, he has brought his A1C from 9.1% to 7.7%.

“This is the best I’ve ever done with this disease,” Santram said. “I feel healthier, have more energy, can think more clearly, and am a more engaged husband, father and grandparent as a result.”

The program makes Santram feel empowered to manage his diabetes and motivated to make lifestyle modifications. He found small short-term goals easier to achieve. Part of his success comes from a better understanding of his medications and improved knowledge of which foods to avoid.

Pilot program was just the beginning

One hundred and twenty-one patients were enrolled in the 2021–2022 pilot. The first participants successfully lowered their A1C and demonstrated a reduction in the distress caused by their diabetes by implementing behavioral, lifestyle, and medication changes, thanks to more frequent contact with a diabetes coach.

During the pilot program, led by UMass Memorial endocrinologists Richard Haas, MD, and Vrushali H. Shah, MD, an average patient entered with an A1C score of 10.4%. Within the first three months, patients saw an average of a 1.7-point drop in their A1C. At the six-month visit, participants experienced a 2.4-point drop in A1C.

One of the reasons for success was a result of better adherence to medications (95% vs. almost zero). A 95% rate is far above national adherence estimates for diabetes patients, which tend to hover around 65%. There was a reduction in diabetes-related stress as measured by a Problem Areas in Diabetes questionnaire.

“The combination of specialty pharmacy support and regular guidance on how to effectively self-manage one’s diabetes has played a central role in the success of the program,” said Haas, who is also an Assistant Professor at UMass Chan Medical School. “By offering both to patients, we’re removing silos of care that they no longer have to navigate.”

Better outcomes, with lower patient costs

Since the start of the program, the UMass Memorial diabetes team attributes success to the high frequency of coach and patient interactions, positive lifestyle changes and financial assistance services — the program keeps patient copays to an average of $5.

After a successful pilot, the Care Coach Program is now being implemented across the DCOE. More than 185 diabetes patients have been enrolled in the program in total. A prerequisite of entering the program is having an A1C above 9.0% even after receiving adequate diabetes education.

The new program continues to grow and affect patients positively through better clinical outcomes, lower out-of-pocket costs for patients, and enhanced patient and provider satisfaction.

“Many of our diabetes patients face challenges on multiple fronts whether it be medication affordability, understanding and adhering to a healthy diet, or adequately monitoring their blood sugar trends,” said Shah, Assistant Professor, UMass Chan Medical School. “Having someone like a care coach who stays in regular contact with our patients and works alongside them to achieve week-over-week, incremental goals has helped patients feel empowered. This has truly been a game changer for our clinic.”

“Our patients have expressed that working with a care coach has increased their motivation to take control of their health, and that setting weekly, short-term goals has helped simplify the complex day-to-day management of diabetes,” Sharma said. “Celebrating the small wins that happen on a daily basis has also helped patients feel motivated and empowered.”

View more stories of healing, advancing medicine and innovating from UMass Memorial Health. 


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