A new, grant-funded program at The Dimock Center in Roxbury aims to remove barriers to the proper care and management of diabetes.

For three hours each week, the Dimock Difference in Diabetes clinic offers appointments with an endocrine specialist, along with immediate access to a clinical pharmacist, registered dietitian and licensed social worker for patients with particularly high blood sugar.

"So usually, in a diabetes clinic, you would see a diabetes educator, maybe a nutrition person,” said Dr. Jagriti Upadhyay, the clinic's endocrinologist. “But to have clinical pharmacy, behavioral health and a resource person is extremely rare."

“When I joined Dimock [in 2017], we realized we have a lot of patients with uncontrolled diabetes,” Upadhyay said. “And that’s when we got this idea of starting a diabetes clinic only to take care of patients with uncontrolled diabetes.”

Upadhyay said the team realized they could benefit from grant support after they began working to purchase medical equipment for testing and monitoring patients’ blood sugar levels in-house. They were awarded a two-year, $200,000 grant from the National Association of Community Health Centers, a charity and a medical technology company.

Other health centers are ramping up their efforts to address diabetes as well. Last year, the Health Resources and Services Administration — a federal agency responsible for “improving health care to people who are geographically isolated, economically or medically vulnerable” — launched a Diabetes Quality Improvement Initiative in light of data suggesting that one in seven health center patients has diabetes. Under the initiative, HRSA-funded health centers must document what they’re doing to address the condition and present diabetes data when the agency conducts on-site audits.

A person’s diabetes is considered “uncontrolled” when an A1C blood sugar test yields a number above nine. Upadhyay said that’s about a quarter of the Dimock Center’s diabetes patients. The clinic's team has set a goal to reduce the number of patients with uncontrolled diabetes to 16 percent within the next two years.

In addition to the team approach, Dimock has begun screening diabetes patients’ social needs with a questionnaire about personal issues like food, childcare, transportation and housing. When patients identify those needs or show signs of behavioral health challenges, they have immediate access to the clinic’s social worker.

“We find a lot of times we’ll lose folks,” said Joanna Packer, the on-call social worker. Packer said life stressors, costs, and even lack of enthusiasm can hinder patients from showing up to behavioral health referral appointments. That’s why the immediate access is crucial.

“Because so much of diabetes management is behavioral, and people have such an emotional relationship with a chronic illness and what it means to have to care for that every day and take medications and come to doctors visits," said Packer, "I think it's a really important piece of the puzzle in diabetes management."

The Whittier Street Health Center in another part of Roxbury has prioritized diabetes care since before the HRSA mandate, according to Frederica Williams, that center's CEO.

“When you look at the epidemic, especially for the populations that we serve, it’s a major cost factor,” Williams said. Both Whittier and Dimock serve majority-minority populations, and at both, more than 50 percent of patients live in poverty.

“Controlling diabetes saves healthcare dollars,” said Williams, pointing to HRSA’s estimate that a slight reduction in blood sugar among uncontrolled diabetes patients could save about $3.44 billion over a three-year span. “When you look at that kind of impact, it makes sense for them as they’re investing health centers to look at how we can impact the cost of diabetes while, of course, improving the health of patients.”

This year, Whittier is integrating clinical pharmacy and telemedicine check-ups to help patients manage their diabetes.

Medical specialists agree that a team approach is crucial to caring for the complex condition.

Dr. William Cefalu, chief scientific, medical and mission officer with the American Diabetes Association, said that kind of collaboration is necessary because diabetes is a complex condition that requires lifelong treatment. He said that while the diabetes association doesn’t advocate for any specific health system structure, “integration of multi-specialty care and support programs, such as mental health and nutrition counseling, are critical to removing barriers to care and improving health outcomes.”

Because Dimock has been operating its clinic only since last fall, there are no public data on the program’s effectiveness so far. Upadhyay said she is seeing patients return for additional appointments with herself and the other specialists, which is a good sign.

"And that's why we just wanted to pilot it and see how it works," she said. "I mean, it takes a long time for that visit, but it seems patients definitely get better engaged and they come back."