BRIEF COMMUNICATION

Improving Diabetes Care for Minority, Uninsuredand Underserved Patients

Jose E. Rodrıguez • Kendall M. Campbell •

Otis W. Kirksey

� Springer Science+Business Media New York 2013

Abstract A local safety net clinic provides pharmacy

directed Diabetes Disease Management (DDM). The pur-

pose of the study was to determine if a program like this

would be successful in an underserved, uninsured poor

minority population. Clinic providers referred patients to

the DDM visits. Body Mass Index (BMI), low-density

lipoprotein, high-density lipoprotein (HDL), triglycerides

and hemoglobin A1c (HbA1c) were recorded pre- and post-

intervention. Those who participated in pre-intervention

and post-intervention visit were included in the study and

laboratory values were compared. Participants in the pilot

study showed statistically significant improvements in

HbA1c, triglycerides and BMI. HDL values did not show

statistical change. Pharmacy directed DDM can be effec-

tive in the reduction of HbA1c and triglycerides. It also

may be an effective weight loss intervention for patients

with diabetes.

Keywords Diabetes care � Underserved � Uninsured �Diabetes education � Pharmacy directed diabetes care

Background

Diabetes care can be challenging and frustrating, especially

when dealing with underserved and uninsured minority

populations that may have extreme social and economic

needs [1]. Many interventions have attempted to improve

glycemic control and decrease morbidity and mortality, but

few have been tested in underserved populations [2]. Dia-

betes and its related problems are costly to the health care

system. Recent data suggests that the US spends $306

billion annually in diabetes care [3]. As health care reform

is implemented, it is imperative that we find a way to assist

medically underserved and minority patients in their per-

sonal battles with diabetes in an effort to both reduce cost

and improve outcomes.

Neighborhood Medical Center (NMC) is a not-for-profit

clinic that provides clinical care for members of our com-

munity who are uninsured, underinsured, or recipients of

Medicaid or Medicare. As of the latest needs assessment, we

serve a population that is 60 % African American, 10 %

Hispanic or Latino, and 30 % Caucasian and other groups.

Ninety-four percent of our patients are uninsured self-pay

patients who reimburse the clinic on a sliding payment scale.

Almost 90 % of the patients pay the minimum amount,

which is currently $5. The remaining 6 % of patients have

Medicaid or Medicare [4]. Like many clinics for the under-

served, our clinic depends on funding from various charities

alongside the reimbursement patients can provide. Our

patient population also has a high prevalence of diabetes.

This study describes an intervention that can help in

diabetes management for uninsured patients. The Diabetes

J. E. Rodrıguez (&)

The Center for Underrepresented Minorities in Academic

Medicine, The Florida State University, 1115 West Call Street

#3210M, Tallahassee, FL 32306, USA

e-mail: jose.rodriguez@med.fsu.edu

K. M. Campbell

The Center for Underrepresented Minorities in Academic

Medicine, The Florida State University, 1115 West Call Street

#3210N, Tallahassee, FL 32306, USA

e-mail: kendall.campbell@med.fsu.edu

O. W. Kirksey

The College of Pharmacy and Pharmaceutical Sciences, Florida

Agricultural and Mechanical University, 438 West Brevard St,

Tallahassee, FL 32301, USA

e-mail: otis.kirksey@famu.edu

123

J Immigrant Minority Health

DOI 10.1007/s10903-013-9965-7

Disease Management (DDM) program employs techniques

known to be effective for obesity [5] and diabetes. We

sought to test the hypothesis that DDM can be effective in

improving glycemic control in underserved and uninsured

minority patients.

At NMC, primary care is provided by family physicians

and nurse practitioners, some of whom are contracted or

volunteer their time. These volunteer physicians provide

services ranging from orthopedics, dermatology, and

gynecology. Additionally, a group of volunteer optome-

trists provide eye care to our patients. A county-sponsored

network of volunteer physicians, known as WeCare, pro-

vides those specialty services not provided on-site [4].

Patients who qualify for this program can receive virtually

any procedure at no cost to them. The WeCare program is

separate from the volunteering that occurs on-site. Many of

our on-site volunteer providers also see WeCare patients in

their private offices and hospitals, again at no cost to the

patients.

Theoretical/Conceptual Framework

Through collaboration with Florida Agricultural and

Mechanical University (FAMU), two pharmacists provide

services to the clinic at no charge. One pharmacist oversees

the dispensing pharmacy that serves the patients of the

NMC. Here, patients can receive most of their medications

at a discounted price. The other pharmacist, who is also a

Certified Diabetes Educator (CDE) provides individual

DDM during regularly scheduled office visits. Because of

the affiliation with the local universities, Medical and

Pharmacy students participate in the care of patients as a

part of their clinical rotation experiences.

Obtaining medications can be a challenge for low-

income patients, principally because of cost [6, 7]. To

address this challenge, the dispensing pharmacist super-

vises the medication distribution from the FAMU-operated

pharmacy located just across the hall from the clinic.

Medications are provided at a discounted rate, enabling

easier access for our patients. The pharmacist also works

with the patients who need emergency medications, and

supervises the patient assistance program (PAP). The PAP

allows patients to receive 3 months of medicine at no cost

provided the patient meets set financial criteria. This

enables many diabetic patients access certain costly brand

medications.

Inter-disciplinary collaboration is essential when work-

ing in safety net practices [6, 8]. The central feature of our

model is collaboration, as illustrated in Fig. 1. The PharmD/

CDE and primary care providers work together in seeking

the best outcome for the patients. The PharmD/CDE con-

sults with the treating physician, alerting him or her to

potential adverse effects as well as optimal medical man-

agement from a pharmacotherapeutic point of view. The

PharmD/CDE also provides additional services listed in

Table 1. These services can be difficult, if not impossible

for the primary care physician to provide due to time con-

straints. The PharmD/CDE spends 1 h with each new

patient, and 30 min in each follow up visit.

Methods

In order to determine the impact of these services, we

implemented a quality improvement study, which was

approved by the Institutional Review Board at FAMU.

Participants

Patients were selected by their primary care providers to

participate in the program. Patients with type 1 or type 2

diabetes who saw a primary care provider were encouraged

to attend DDM visits with the PharmD/CDE, and

were referred. Patients who kept pre-intervention and

Fig. 1 Pharmacy managed Diabetes Care Model

Table 1 Services renedered by PharmD/CDE

Services provided during patient encounters

Nutritional counseling Diabetes self-management

education

Carbohydrate counting Compliance and adherence

issues

Healthy food selections Development of patient specific

care plansFood labels

Weight-loss education and

advocacy

Medication dosage adjustments

Group Visits In conjunction with primary care

providers

Diabetic foot assessment for

sensory deficits

Review and interpretation of

laboratory data

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post-intervention DDM appointments were included in the

study and were followed for 6 months.

Data Collection and Measures

The PharmD/CDE measured hemoglobin A1c, (HbA1c)

triglycerides, low density lipoproteins (LDL), high density

lipoproteins (HDL) and Body Mass Index (BMI) at the pre-

intervention visit and the post-intervention visit. Only

patients whose data set was complete were included in the

study. Patients missing any data were not included in this

analysis.

Analysis

Patients HbA1c, triglycerides, and HDL levels were aver-

aged for pre-intervention and post-intervention groups and

were subsequently compared. LDL data sets were not

complete due to multiple patients with triglycerides too

elevated to calculate LDL, so the LDL results could not be

compared. Statistical analysis was performed using SPSS.

Results

There were 36 patients that met criteria for inclusion in the

study. Additional patient demographic data is listed in

Table 2. Pre- and post-intervention data are illustrated in

‘‘Appendix’’. Results suggest that after one DDM visit

HbA1c (pre = 8.57 %, post 7.44 %, p \ 0.05), triglycer-

ides (pre = 236, post = 15.66, p \ 0.05), and BMI

(pre = 42, post 35.16, p \ 0.05) can be significantly

reduced. HDL levels, however, did not increase signifi-

cantly (pre = 44, post = 44.38, p [ 0.05).

Discussion

Treatment of diabetes among the underserved is difficult

and sometimes frustrating [6]. Lack of resources makes it

difficult for patients to keep appointments, and to consis-

tently purchase medications [4]. In spite of these existing

obstacles, those patients who consulted with the PharmD/

CDE for DDM over the study period had significant

decreases in HbA1c, triglycerides, and BMI. These find-

ings show that patients who participate in PharmD/CDE

DDM along with primary care collaboration can have

improvements in a relatively short period of time. This

finding holds promise, as it may be another modality that

can be used in the fight against obesity, in addition to group

visits and other collaborations [5].

Our study had some significant challenges and limita-

tions, one of which was a small study population. This was

due in part to the newness of the program, as well as the

difficulties involved in following a patient population as

transient as ours. Frequently, patients will obtain employ-

ment that provides commercial health insurance and leave

our practice. Another limitation was the brief time period

of the study. We suspect a longer time frame would be

beneficial, as it would allow an assessment of the potential

for lasting change.

Our study has also indicated future directions for

research. Based on these findings, a 3-year case control

study is indicated to determine the difference between

usual care and the PharmD/CDE collaborative model. We

will also encourage all of our patients to continue with their

DDM, as it is effective for those who were seen more than

once. In the future, a more detailed analysis of the patients

who did not continue with diabetes management can be

performed to identify barriers and propose solutions for

that segment of our patient population, using qualitative

measures.

New Contribution to the Literature

This study adds to the current medical literature as it

illustrates that DDM given by a PharmD/CDE can be

effective in an uninsured, underserved minority population.

In addition, it is an effective tool in promoting and

achieving clinically significant weight loss.

Appendix

See Fig. 2.

Table 2 Demographic data of study participants

Intervention cohort (N = 36)

African American 15

Caucasian 10

Hispanic or Latino 1

Not declared 10

Males 16

Females 20

Average age 51

Average follow up time (months) 6

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Fig. 2 Summary of laboratory findings pre- and post-intervention

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