Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes.

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Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine


oregon; core; Humans; Adolescent; Young Adult; Adult; Middle Aged; Aged; Diabetes Mellitus, Type 2; Glycated Hemoglobin; Blood Pressure; Patients; Mass Screening; Social Determinants of Health


Background: The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact.

Objective: We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services.

Design: The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups.

Participants: Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020.

Interventions: The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention.

Main measures: Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization.

Key results: Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed.

Conclusions: DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Keywords: Diabetes mellitus; Health disparities; Social determinants of health.

Clinical Institute

Kidney & Diabetes




Population Health