Diabetes Care Volume 47, Supplement 1, January 2024 S11

1. Improving Care and Promoting American Diabetes Association

Professional Practice Committee*
Health in Populations: Standards
of Care in Diabetes—2024
Diabetes Care 2024;47(Suppl. 1):S11–S19 | https://doi.org/10.2337/dc24-S001

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1. IMPROVING CARE AND PROMOTING HEALTH
The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-
cludes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, a interprofessional expert committee, are responsible for
updating the Standards of Care annually, or more frequently as warranted. For a
detailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. Readers who wish to comment on the Standards of Care are
invited to do so at https://professional.diabetes.org/SOC.

DIABETES AND POPULATION HEALTH

Recommendations
1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines,
capture key elements within the social determinants of health, and are made
collaboratively with people with diabetes and care partners based on individual
preferences, prognoses, comorbidities, and informed financial considerations. B
1.2 Align approaches to diabetes management with the Chronic Care Model. This
model emphasizes person-centered team care, integrated long-term treatment
approaches to diabetes and comorbidities, and ongoing collaborative communi-
cation and goal setting between all team members. A
1.3 Care systems should facilitate in-person and virtual team-based care, in-
clude those knowledgeable and experienced in diabetes management as part
of the team, and utilize patient registries, decision support tools, and commu-
nity involvement to meet needs of individuals with diabetes. B *A complete list of members of the American
1.4 Assess diabetes health care maintenance (Table 4.1) using reliable and relevant Diabetes Association Professional Practice Committee
data metrics to improve processes of care and health outcomes, with attention to can be found at https://doi.org/10.2337/dc24-SINT.
care costs, individual preferences and goals for care, and treatment burden. B Duality of interest information for each author is
available at https://doi.org/10.2337/dc24-SDIS.
Suggested citation: American Diabetes Association
Population health is defined as “the health outcomes of a group of individuals, in- Professional Practice Committee. 1. Improving care
cluding the distribution of health outcomes within the group”; these outcomes can and promoting health in populations: Standards
be measured in terms of health outcomes (mortality, morbidity, and functional sta- of Care in Diabetes—2024. Diabetes Care 2024;
47(Suppl. 1):S11–S19
tus), disease burden (incidence and prevalence), and behavioral and metabolic fac-
tors (physical activity, nutrition, A1C, etc.) (1). Clinical practice recommendations © 2023 by the American Diabetes Association.
for health care professionals are tools that can ultimately improve health across Readers may use this article as long as the
work is properly cited, the use is educational
populations; however, for optimal outcomes, diabetes care must also be individual- and not for profit, and the work is not altered.
ized for each person with diabetes and across their life span. Thus, efforts to improve More information is available at https://www
population health will require a combination of policy-level, system-level, and .diabetesjournals.org/journals/pages/license.
S12 Improving Care and Promoting Health in Populations Diabetes Care Volume 47, Supplement 1, January 2024

person-level approaches. With such an living with diabetes. Certain segments of 1. Delivery system design (moving from
integrated approach in mind, the Ameri- the population, such as young adults and a reactive to a proactive care deliv-
can Diabetes Association (ADA) high- individuals with complex comorbidities, ery system where planned visits are
lights the importance of person-centered financial or other social hardships, and/or coordinated through a team-based
care, defined as care that considers an in- limited English proficiency, as well as indi- approach)
dividual’s comorbidities and prognoses; is viduals in ethnic minority populations, 2. Self-management support
respectful of and responsive to individual face particular challenges to goal-based 3. Decision support, particularly at the
preferences, needs, and values; and en- care (5–7). A U.S. population–based study point of care during a clinical en-
sures that the individual’s values guide all based on the National Health and Nutrition counter (basing care on evidence-
clinical decisions (2). Furthermore, wider Examination Survey (NHANES) showed that based, effective care guidelines)
social determinants of health (SDOH)— younger people with diabetes, individuals 4. Clinical information systems (using
often out of direct control of the individ- who are Mexican American or non-Hispanic registries that can provide person-

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ual and potentially representing lifelong Black, those with lower level of educational specific and population-based sup-
risk—contribute to health care and psy- attainment, and those who are underin- port to the care team)
chosocial outcomes and must be ad- sured are most likely to be undertreated, 5. Community resources and policies
dressed to improve all health outcomes particularly for glycemic control (4). The (identifying or developing resources
(3). Clinical practice recommendations, persistent variability in the quality of diabe- to support healthy lifestyles)
whether based on evidence or expert opin- tes care across health care professionals 6. Health systems (to create a quality-
ion, are intended to guide an overall ap- and practice settings indicates that sub- oriented culture)
proach to care. The science and art of stantial system-level improvements are
health care come together when the clini- still needed. A 5-year effectiveness study of the
cian makes treatment decisions for a per- Diabetes and its associated health CCM in 53,436 people with type 2 diabe-
son who may not meet the eligibility complications pose a significant finan- tes in the primary care setting suggested
criteria used in the studies on which guide- cial burden to individuals and society. It that the use of this model of care deliv-
lines are based. Recognizing that one size is estimated that the annual cost of di- ery reduced the cumulative incidence
does not fit all, the standards presented agnosed diabetes in the U.S. in 2022 of diabetes-related complications and
here provide guidance for when and how was $413 billion, including $307 billion all-cause mortality (11). Individuals who
to adapt recommendations for an individ- in direct health care costs and $106 bil- were enrolled in the CCM experienced a
ual. This section provides guidance for lion in reduced productivity. After ad- reduction in cardiovascular disease risk
health care professionals as well as health justing for inflation, the economic costs by 56.6%, microvascular complications by
systems, payers, and policymakers. of diabetes increased by 7% between 11.9%, and mortality by 66.1% (11). In
2017 and 2022 and by 35% from 2012 addition, another study suggested that
Status and Demographics of Diabetes to 2022 (8). This is attributed to the in- health care utilization was lower in the
Care creased prevalence of diabetes and the CCM group, which resulted in health care
The proportion of people with diabetes increased cost per person with diabetes. savings of $7,294 per individual over the
who achieve recommended A1C, blood People living with diabetes also face fi- study period (12).
pressure, and LDL cholesterol levels has nancial hardship, which is correlated Redefining the roles of the health care
fluctuated over the years, with some with higher A1C, diabetes distress, and delivery team and empowering self-
improvement over time (4). Glycemic depressive symptoms (9). Therefore, on- management of people with diabetes
management and management of cho- going population health strategies like are fundamental to the successful imple-
lesterol through dietary intake remain the Chronic Care Model (CCM) are needed mentation of the CCM (13). Collabora-
challenging. In 2015–2018, just 50.5% to reduce costs to the health care system tive, interprofessional teams are best
of U.S. community-dwelling adults with and to people with diabetes and to pro- suited to provide care for people with
diabetes achieved A1C <7% and 75.4% vide optimized care. chronic conditions such as diabetes and
achieved A1C <8%. The goal blood pres- to facilitate individuals’ self-management
sure of <130/80 mmHg was achieved by Chronic Care Model (14–16). There are references to guide
just 47.7% adults with diabetes, while Numerous interventions to promote the the implementation of the CCM into dia-
70.4% achieved blood pressure <140/90 recommended standards have been im- betes care delivery, including opportuni-
mmHg. Lipid control, then defined as plemented. However, a major barrier to ties and challenges (17).
non-HDL cholesterol <130 mg/dL, was optimal care is a delivery system that is
achieved by 55.7% adults with diabetes, often fragmented, lacks clinical informa- Strategies for System-Level Improvement
and all three risk factors were controlled tion capabilities, duplicates services, and Optimal diabetes management requires
by just 22.2%. Importantly, many people is poorly designed for the coordinated an organized, systematic approach and
who did not attain A1C, blood pressure, delivery of chronic care. The CCM is a the involvement of a coordinated team
and lipid goals are not receiving any or commonly used framework for describ- of dedicated health care professionals
adequate pharmacotherapy for glycemic, ing diabetes care programs (10). working in an environment where per-
hypertension, and dyslipidemia manage- son-centered, high-quality care is a pri-
ment, respectively, which underscores the Six Core Elements.The CCM includes six ority (7,17–19). While many diabetes
vital and urgent need for care delivery core elements to optimize the care of care processes have improved nation-
systems to engage and support people people with chronic disease: ally in the past decade, the overall
diabetesjournals.org/care Improving Care and Promoting Health in Populations S13

quality of care for people with diabetes case management, and patient education education and clinical support and remove
remains suboptimal (4). Efforts to in- resources) (7); and incorporating care geographic and transportation barriers for
crease the quality of diabetes care include management teams including nurses, individuals living in under-resourced areas
providing care that is concordant with dietitians, pharmacists, and other health or with disabilities (55). Telehealth resour-
evidence-based guidelines (20); expanding care professionals (21,42). In addition, ces can also have a role in addressing the
the role of teams to implement more in- initiatives such as the Patient-Centered SDOH in young adults with diabetes (56).
tensive disease management strategies Medical Home can improve health out- However, limited data are available on the
(7,16,21,22); tracking medication-taking comes by fostering comprehensive pri- effectiveness across different populations
behavior at a systems level (23); rede- mary care and offering new opportunities (57).
signing the organization of the care pro- for team-based chronic disease manage-
cess (24); implementing electronic health ment (43,44). Behaviors and Well-being
record (EHR) tools (25,26); empowering Successful diabetes care also requires a sys-

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and educating people with diabetes Telehealth tematic approach to supporting the behavior-
(27,28); removing financial barriers and Telehealth is a growing field that may in- change efforts of people with diabetes.
reducing patient out-of-pocket costs for crease access to care for people with diabe- High-quality diabetes self-management
diabetes education, eye exams, diabetes tes. The American Telemedicine Association education and support (DSMES) has
technology, and essential medications defines telemedicine as the use of medical been shown to improve patient self-
(7,29); leveraging telehealth capabilities information exchanged from one site to an- management, satisfaction, and glucose
to improve access to care (30); assess- other via electronic communications to outcomes. National DSMES standards call
ing and addressing psychosocial issues improve a patient’s clinical health status. for an integrated approach that includes
(31,32); and identifying, developing, and Telehealth includes a growing variety of clinical content and skills, behavioral strat-
engaging community resources and pub- applications and services using two-way egies (goal setting, problem-solving), and
lic policies that support healthy lifestyles video, smartphones, wireless tools, and engagement with psychosocial concerns.
(33). The National Diabetes Education Pro- other forms of telecommunications tech- Increasingly, such support is being adapted
gram maintains an online resource (cdc. nology (45). Often used interchangeably for online platforms that have the poten-
gov/diabetes/professional-info/training. with telemedicine, telehealth describes a tial to promote patient access to this im-
html) to help health care professionals broader range of digital health services in portant resource. These curriculums need
design and implement more effective health care delivery (46). This includes to be tailored to the needs of the intended
health care delivery systems for those synchronous, asynchronous, and remote populations, including addressing the
with diabetes. Given the pluralistic needs patient monitoring. “digital divide,” i.e., access to the technol-
of people with diabetes and that the Telehealth should be used comple- ogy required for implementation (58–61).
constant challenges they experience vary mentary to in-person visits to optimize For more information on DSMES, see
over the course of disease management glycemic management in people with un- Section 5, “Facilitating Positive Health
(complex insulin treatment plans, new managed diabetes (47). Increasingly, evi- Behaviors and Well-being to Improve
technology, etc.), a diverse team with dence suggests that various telehealth Health Outcomes.”
complementary expertise is consistently modalities may facilitate reducing A1C in
recommended (34). people with type 2 diabetes compared Cost Considerations for Medication-Taking
with usual care or in addition to usual Behaviors
Care Teams care (48), and findings suggest that tele- The cost of diabetes medications and de-
The care team, which centers around medicine is a safe method of delivering vices is an ongoing barrier to achieving
the person with diabetes, should avoid care for people with type 1 diabetes in glycemic goals. Up to 25% of people
therapeutic inertia and prioritize timely rural areas (49). For rural populations with diabetes who are prescribed insulin
and appropriate intensification of be- or those with limited physical access to report cost-related insulin underuse (62).
havior change (nutrition and physical health care, telemedicine has a growing Insulin underuse due to cost has also
activity) and/or pharmacologic therapy body of evidence for its effectiveness, been termed “cost-related medication
for individuals who have not achieved particularly with regard to glycemic man- non-adherence” (here referred to as cost-
the recommended metabolic goals (35–37). agement as measured by A1C (30,50–52). related barriers to medication use). There
Strategies shown to improve care team In addition, evidence supports the effec- are recommendations from the ADA Insu-
behavior and thereby catalyze reductions tiveness of telehealth in diabetes, hyper- lin Access and Affordability Working
in A1C, blood pressure, and/or LDL cho- tension, and dyslipidemia interventions Group for approaches to this issue from a
lesterol include engaging in explicit and (53) as well as the telehealth delivery of systems level (63). Recommendations in-
collaborative goal setting with people motivational interviewing (54). Interactive cluding concepts such as cost-sharing for
with diabetes (38,39); integrating evi- strategies that facilitate communication insured people with diabetes should be
dence-based guidelines and clinical infor- between health care professionals and based on the lowest price available, the
mation tools into the process of care people with diabetes, including the use of list price for insulins that closely reflects
(20,40,41); identifying and addressing web-based portals or text messaging and the net price, and health plans that ensure
language, numeracy, or cultural barriers those that incorporate medication adjust- people with diabetes can access insulin
to care (41–43); soliciting performance ment, appear more effective. Telehealth without undue administrative burden or
feedback, setting reminders, and providing and other virtual environments can also be excessive cost (63). In 2023, three major
structured care (e.g., guidelines, formal used to offer diabetes self-management insulin manufacturers lowered the prices
S14 Improving Care and Promoting Health in Populations Diabetes Care Volume 47, Supplement 1, January 2024

of insulin, which may help reduce the fi- transformation for diabetes care are avail- been associated with greater risk for dia-
nancial burden of diabetes management, able from the National Institute of Diabe- betes, higher population prevalence, and
although costs for insulin delivery and glu- tes and Digestive and Kidney Diseases poorer diabetes outcomes (82–86). SDOH
cose monitoring remain high. People with guidance on diabetes care and quality are defined as the economic, environ-
diabetes should be screened for financial (75) Using patient registries and EHRs, mental, political, and social conditions in
burden of treatment, cost-related bar- health systems can evaluate the quality which people live and are responsible for
riers to medication use, and rationing of of diabetes care being delivered and per- a major part of health inequality world-
other essential services due to medical form intervention cycles as part of quality wide (87). Greater exposure to adverse
costs (64). improvement strategies (76). Improve- SDOH over the life course results in poor
The cost of medications (not only insu- ment of health literacy and numeracy is health (88). The ADA recognizes the asso-
lin) influences prescribing patterns and also a necessary component to improve ciation between social and environmental
medication use because of burden on the care (77,78). Critical to these efforts is factors and the prevention and treatment

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person with diabetes and lack of second- health professional adherence to clinical of diabetes and has issued a call for re-
ary payer support (public and private practice recommendations (Table 4.1) search that seeks to better understand
insurance) for effective approved glu- and the use of accurate, reliable data how social determinants influence behav-
cose-lowering, cardiovascular disease metrics that include sociodemographic iors and how the relationships between
risk-reducing, and weight management variables to examine health equity within these variables might be modified for the
therapeutics. Financial barriers remain a and across populations (79). prevention and management of diabetes
major source of health disparities, and In addition to quality improvement ef- (89,90). While a comprehensive strategy
costs should be a focus of treatment goals forts, other strategies that simultaneously to reduce diabetes-related health inequi-
(65). (See TAILORING TREATMENT FOR SOCIAL CON- improve the quality of care and potentially ties in populations has not been formally
TEXT and TREATMENT CONSIDERATIONS.) Reduction reduce costs are gaining momentum and studied, general recommendations from
in cost-related barriers to medication use include reimbursement structures that, in other chronic disease management and
is associated with better biologic and psy- contrast to visit-based billing, reward the prevention models can be drawn upon to
chologic outcomes, including quality of provision of appropriate and high-quality inform systems-level strategies in diabetes
life (66). care to achieve metabolic goals (80), value- (91). For example, the National Academy
based payments, and incentives that ac- of Medicine has published a framework
Access to Care and Quality Improvement commodate personalized care goals (7,81). for educating health care professionals on
The Affordable Care Act and Medicaid ex- (Also see COST CONSIDERATIONS FOR MEDICATION- the importance of SDOH (92). Further-
pansion have increased access to care for TAKING BEHAVIORS, above, regarding cost- more, there are resources available for
many individuals with diabetes, empha- related barriers to medication use.) the inclusion of standardized sociodemo-
sizing the protection of people with pre- graphic variables in EHRs to facilitate the
existing conditions, health promotion, and measurement of health inequities and
disease prevention (67). In fact, health in- TAILORING TREATMENT FOR the impact of interventions designed to
surance coverage increased from 84.7% in SOCIAL CONTEXT reduce those inequities (74,92,93).
2009 to 90.1% in 2016 for adults with dia- SDOH are not consistently recognized
betes aged 18–64 years. As of early 2022, Recommendations
and often go undiscussed in the clinical
more than 35 million people in the U.S. 1.5 Assess food insecurity, housing inse- encounter (85). Among people with chronic
were enrolled in some form of Affordable curity/homelessness, financial barriers, illnesses, two-thirds of those who re-
Care Act–related health insurance (68). and social capital/social community ported not taking medications as pre-
Coverage for those aged $65 years re- scribed due to cost-related barriers to
support to inform treatment deci-
mained nearly universal (69). People with medication use never shared this with
sions, with referral to appropriate lo-
diabetes who have either private or public their physician (94). A study using data
cal community resources. A
insurance coverage are more likely to from the National Health Interview Survey
1.6 Provide people with diabetes with
meet quality indicators for diabetes care (NHIS) (85) found that one-half of adults
additional self-management support
(70). As mandated by the Affordable Care with diabetes reported financial stress
from lay health coaches, navigators,
Act, the Agency for Healthcare Research and one-fifth reported food insecurity. A
or community health workers when
and Quality developed a National Quality Canadian study noted an association of
available. A
Strategy based on triple aims that include one or more adverse SDOH and health
1.7 Consider the involvement of com-
improving the health of a population, care utilization and poor diabetes out-
overall quality and patient experience of munity health workers to support the comes in high-risk children with type 1 di-
care, and per capita cost (71,72). As health management of diabetes and cardio- abetes (94). It is therefore important for
care systems and practices adapt to the vascular risk factors, especially in un- people with diabetes to be screened for
changing landscape of health care, it will derserved communities and health SDOH during clinical encounters and be
be important to integrate traditional dis- care systems. B referred to appropriate clinical and com-
ease-specific metrics with measures of munity resources to address these needs.
patient experience, as well as cost, in Health systems may benefit from compil-
assessing the quality of diabetes care Health inequities related to diabetes and ing an inventory of such resources to fa-
(73,74). Information and guidance spe- its complications are well documented, cilitate referrals at the point of care.
cific to quality improvement and practice are heavily influenced by SDOH, and have Policies and payment models that support
diabetesjournals.org/care Improving Care and Promoting Health in Populations S15

addressing SDOH, both within and outside to have emergency department visits and with diabetes who are homeless need se-
the health care setting, are needed to en- hospitalizations compared with older cure places to keep their diabetes supplies
sure that these efforts are both feasible adults who do not report food insecurity and refrigerator access to properly store
and sustainable. One example of a state- (105). Risk for food insecurity can be as- their insulin and take it on a regular sched-
wide payment model that incentivizes sessed with a validated two-item screening ule. The risk for homelessness can be ascer-
value-based care, addressing SDOH and- tool (106) that includes the following state- tained using a brief risk assessment tool
funding community-based health care pro- ments: 1) “Within the past 12 months, we developed and validated for use among
fessionals, is the Maryland Total Cost of worried whether our food would run out veterans (112). Housing insecurity has also
Care Model, although it is currently limited before we got money to buy more” and been shown to be directly associated with
by a narrow focus such as preventing dia- 2) “Within the past 12 months the food we a person’s ability to maintain their diabetes
betes rather than overall diabetes care bought just didn’t last, and we didn’t have self-management (113). Given the poten-
quality (95,96). money to get more.” An affirmative re- tial challenges, health care professionals

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Another population in which such is- sponse to either statement had a sensitivity who care for either homeless or housing-
sues must be considered is older adults, of 97% and specificity of 83%. Interventions insecure individuals should be familiar with
for whom social difficulties may impair such as food prescription programs are con- resources or have access to social workers
quality of life and increase the risk of sidered promising to address food insecu- who can facilitate stable housing for these
functional dependency (97) (see Section rity by integrating community resources individuals as a way to improve diabetes
13, “Older Adults,” for a detailed discus- into primary care settings and directly deal- care (114).
sion of social considerations in older ing with food deserts in underserved com-
adults). Creating systems-level mechanisms munities (107,108). Migrant and Seasonal Agricultural
to screen for SDOH may help overcome Workers
structural barriers and communication gaps Treatment Considerations Migrant and seasonal agricultural workers
between people with diabetes and health In those with diabetes and food insecurity, may have a higher risk of type 2 diabetes
the priority is mitigating the increased risk than the overall population. While migrant
care professionals (85,98). Pilot studies
for uncontrolled hyperglycemia and se- farmworker–specific data are lacking, most
have proven the effectiveness of identify-
vere hypoglycemia. The reasons for the agricultural workers in the U.S. are Latino, a
ing SDOH by using validated screening
increased risk of hyperglycemia include population with a high rate of type 2 diabe-
tools (99). In addition, brief, validated
the steady consumption of inexpensive tes. In addition, living in severe poverty
screening tools for some SDOH exist and
carbohydrate-rich processed foods, binge brings with it food in-security, high chronic
could facilitate discussion around factors
eating, financial constraints to filling dia- stress, and an increased risk of diabetes;
that significantly impact treatment during
betes medication prescriptions, and anxiety there is also an association between the
the clinical encounter. Below is a discus-
and depression leading to poor diabetes use of certain pesticides and the incidence
sion of assessment and treatment consid-
self-care behaviors. Hypoglycemia can of diabetes (115).
erations in the context of food insecurity,
occur due to inadequate or erratic car- Data from the Department of Labor in-
homelessness, limited English proficiency, dicate that there are 2.5–3 million agricul-
bohydrate consumption following the
limited health literacy, and low literacy. tural workers in the U.S. These agricultural
administration of sulfonylureas or insu-
lin. See Tables 9.2–9.4 for drug-specific workers travel throughout the country,
Food Insecurity serving as the backbone for a multibillion-
and patient factors, including cost and
Food insecurity is the unreliable avail- risk of hypoglycemia, which may be im- dollar agricultural industry. According to
ability of nutritious food and the inability portant considerations for adults with 2021 health center data, 175 health cen-
to consistently obtain food without re- food insecurity and type 2 diabetes. ters across the U.S. reported that they
sorting to socially unacceptable practi- Health care professionals should con- provided health care services to 893,260
ces. Over 18% of the U.S. population sider these factors when making treat- adult agricultural patients, and 91,124
reported food insecurity between 2005 ment decisions for people with food had encounters for diabetes (10.2%) (116).
and 2014 (100). The rate is higher in insecurity and seek local resources to Migrant farmworkers encounter numer-
some racial and ethnic minority groups, help people with diabetes and their fam- ous and overlapping barriers to receiving
including African American and Latino ily members obtain nutritious food more care. Migration, which may occur as fre-
populations, low-income households, and regularly (109). quently as every few weeks for farm-
homes headed by single mothers. The workers, disrupts care. In addition, cultural
food insecurity rate in individuals with Homelessness and Housing and linguistic barriers, lack of transporta-
diabetes may be up to 20% (101). Addi- Insecurity tion and money, lack of available work
tionally, the risk for type 2 diabetes is Homelessness and housing insecurity of- hours, unfamiliarity with new communi-
increased twofold in those with food in- ten accompany other barriers that limit ties, lack of access to resources, and other
security (89) and has been associated diabetes self-management. Food insecu- barriers prevent migrant farmworkers
with lower engagement in self-care be- rity, lack of insurance, cognitive impair- from accessing health care. Without regu-
haviors and medication use, depression, ment, behavioral health deficiencies, and lar care, those with diabetes may suffer se-
diabetes distress, and worse glycemic low literacy and numeracy skills are also vere and often expensive complications
management when compared with individ- factors (110). The prevalence of diabetes that affect quality of life. Nontraditional
uals who are food secure (102–104). Older in the homeless population is estimated care delivery models, including mobile in-
adults with food insecurity are more likely to be around 8% (111). Additionally, people tegrated health and telehealth, can be
S16 Improving Care and Promoting Health in Populations Diabetes Care Volume 47, Supplement 1, January 2024

leveraged to improve access to high qual- populations with low literacy (119). How- likely to benefit from such intervention
ity care. ever, evidence supporting these strategies strategies.
Health care professionals should be at- is largely limited to observational studies. Health care community linkages are re-
tuned to all patients’ working and living More research is needed to investigate ceiving increasing attention from the Amer-
conditions. For example, if a migrant farm- the most effective strategies for en- ican Medical Association, the Agency for
worker with diabetes presents for care, hancing both acquisition and retention Healthcare Research and Quality, and
appropriate referrals should be initiated of diabetes knowledge and examine others to promote the translation of clini-
to social workers and community resour- different media and strategies for de- cal recommendations for nutrition and
ces, as available, to assist with removing livering interventions to people with physical activity in real-world settings
barriers to care. diabetes (120). (124). Community health workers (CHWs)
Health numeracy is also essential in (125), community paramedics (126), peer
Language Barriers diabetes prevention and management. supporters (127–129), and lay leaders

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Health care professionals who care for Health numeracy requires primary nu- (130) may assist in the delivery of DSMES
non–English speakers should develop or meric skills, applied health numeracy, and services (92,131), particularly in under-
offer educational programs and materials interpretive health numeracy. An emo- served communities. The American Public
in culturally adaptive languages specific tional component also affects a person’s Health Association defines a CHW as a
to these individuals with the specific goals ability to understand concepts of risk, “frontline public health worker who is a
of preventing diabetes and building dia- probability, and communication of scien- trusted member of and/or has an unusu-
betes awareness in people who cannot tific evidence (121). People with predia- ally close understanding of the commu-
easily read or write in English. The Na- betes or diabetes often need to perform nity served” (132). CHWs can be part of a
tional Standards for Culturally and Lin- numeric tasks such as interpreting food cost-effective, evidence-based strategy to
guistically Appropriate Services in Health labels and blood glucose levels to make improve the management of diabetes
and Health Care (National CLAS Stand- treatment decisions such as medication and cardiovascular risk factors in under-
ards) provide guidance on how health dosing. Thus, both health literacy and nu- served communities and health care sys-
care professionals can reduce language meracy are necessary for enabling effec- tems (133). The CHW scope of practice in
barriers by improving their cultural com- tive communication between people with areas such as outreach and communica-
petency, addressing health literacy, and diabetes and health professionals, arriving tion, advocacy, social support, basic health
ensuring communication with language at a treatment plan, and making diabetes education, referrals to community clinics,
assistance (117). In addition, the National self-management task decisions. If peo- and other services has successfully pro-
CLAS Standards website offers several re- ple with diabetes appear not to under- vided social and primary preventive serv-
sources and materials that can be used to stand concepts associated with treatment ices to underserved populations in rural
improve the quality of care delivery to decisions, both can be assessed using stan- and hard-to-reach communities. Even though
non–English-speaking individuals (117). dardized screening measures (122). Ad- CHWs’ core competencies are not clinical
junctive education and support may be in nature, in some circumstances, clini-
Health Literacy and Numeracy indicated if limited health literacy and nu- cians may delegate limited clinical tasks
Health literacy is defined as the degree to to CHWs. If such is the case, these tasks
meracy are barriers to optimal care deci-
which individuals have the capacity to ob- must always be performed under the di-
sions (31).
tain, process, and understand basic health rection and supervision of the delegating
information and services needed to make health professional and following state
Social Capital and Community
appropriate decisions (77). Health literacy Support
health care laws and statutes (134,135).
is strongly associated with patients engag- Social capital, which comprises community Community paramedics are advanced
ing in complex disease management and and personal network instrumental sup- paramedics with training in chronic dis-
port, promotes better health, whereas ease monitoring and education, medica-
self-care (118). Approximately 80 million
lack of social support is associated with tion management, care coordination, and
adults in the U.S. are estimated to have
SDOH in addition to their emergency
limited or low health literacy (78). Clini- poorer health outcomes in individuals
medical services expertise. While their
cians and diabetes care and education with diabetes (90). Of particular concern
scope of practice varies across states,
specialists should ensure they provide are the SDOH, including racism and dis-
community paramedics can engage and
easy-to-understand information and re- crimination, which are likely to be lifelong
support people living with diabetes under
duce unnecessary complexity when de- (123). These factors are rarely addressed
the direction of a medical director by de-
veloping care plans with people with in routine treatment or disease manage-
livering diabetes education, assisting with
diabetes. Interventions addressing low ment but may be underlying reasons for
medication management, performing health
health literacy in populations with diabe- lower engagement in self-care behaviors
assessments and wound care, and con-
tes seem effective in improving diabetes and medication use. Community resour-
necting people with diabetes and care
outcomes, including ones focusing primar- ces are recognized by the CCM as a core
partners with clinical and community re-
ily on patient education, self-care training, component of chronic care management
sources (126).
or disease management. Combining easily (10), with a particular need to incorporate
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