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From Diabetes Professional to Change Agent: The Shift That Population Health Requires
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From Diabetes Professional to Change Agent: The Shift That Population Health Requires

Mary Caffrey
A leader at the Institute for Healthcare Improvement offers a framework for diabetes educators to embrace a shift in thinking about healthcare delivery.
Moving the healthcare system from taking care of individual patients to taking care of populations demands a series of shifts, changes that transform the professionals who care for people with diabetes from doctors and nurses to change agents, according to a physician who helped undertake such a transformation.

Somava Stout, MD, MS, vice president at the Institute for Healthcare Improvement (IHI), spoke Saturday at the 2018 meeting of the American Association of Diabetes Educators about her experiences at the Cambridge Health Alliance (CHA), an affiliate of Harvard Medical School that provides healthcare in the Cambridge, Somerville, and Boston Metro-North areas in Massachusetts. The integrated delivery system serves 130,000 people—including 50% who speak a language other than English and 70% who are publicly insured.

Stout began with an overview of the Triple Aim—the idea pioneered by former CMS administrator and IHI President Emeritus and Senior Fellow Don Berwick, MD, MPP, that healthcare should simultaneously improve the experience of care, improve the health of populations, and lower per capita costs. “It’s not enough to do one without thinking about the other,” Stout said.

Her message—that the road to better health mostly happens outside the doctor’s office—was a good match for an audience of educators, who by training include nurses, dietitians, pharmacists, exercise specialists, and more. Innovative programs at CHA, such as efforts to teach people with diabetes to shop for healthy groceries, were part of a transformation process that led to better-than-average improvements in health indicators among patients who typically had poor health outcomes.

As medical director, Stout said 2 of the first “change maker agents” were a diabetes educator and a nutritionist on her team. When they started, she said, “People’s A1C seemed to be getting better, but we were seeing some plateaus.”

So, the medical team asked the patients: what can we do to help you manage your diabetes?

“They began to say things to us that we would not have expected,” Stout said. Patients told the team, “What we really need is someone to come shop with us. Or a buddy to come walk with me so I feel safe.” Others mentioned a food co-op to save money purchasing fresh fruits and vegetables. People living with diabetes needed support, which led to a shared medical appointment led by a diabetes educator.

“As we changed the balance of power,” Stout said, “that created insights for us.” Most of the hours people spend living with diabetes is not spent at the doctor’s office, and CHA began to help people better manage those hours away from the clinic.

By listening to the CHA patients and offering them the tools they needed, the health system was able to achieve a 36% reduction in the hospitalization rate for people with diabetes.


Population health, she said, recognizes the significant role that location plays in health outcomes and how the cost of inequity and disease is unsustainable; the most recent estimate from the American Diabetes Association shows the annual cost of prediabetes and diabetes is $322 billion, and those with diabetes have health costs 2.3 times higher than those without the disease. Stout shared maps of Los Angeles County Census tracts that showed how the areas with the highest poverty overlapped the areas with the highest rates of childhood obesity. Similarly, states with the highest rates of diabetes and obesity—like West Virginia, Kentucky, Mississippi, Louisiana, Arkansas, and Alabama—are among the poorest. Stout said data show that race widens the disparity gap in poverty.

“We’ve begun to understand something about the risk of adverse childhood events, and what happens when a child doesn’t have everything they need, and is growing up in a toxic environment of stress,” Stout said. “Of course, it makes sense when you think about it,” she said, as research shows that high stress levels create a stress response that leads to higher levels of prediabetes and diabetes.

“There are chronic space-based inequities that are not accidental,” she said. Decades of redlining and lack of investment mean minority communities have fewer jobs, poorer schools, fewer grocery stores, and fewer parks. It takes longer to get to work, it’s harder and less safe to walk or exercise, and it’s not easy to get fresh food, Stout said. “All of the things that we tell our patients to do aren’t there.”

Thus, the best clinical care in the world won’t drive down healthcare costs if policy makers and communities cannot create conditions that reduce stress and promote health in the first place, she said. Huge differences in life expectancy can occur between children who grow up within a few miles depending on neighborhood quality, based on social determinants of health.

When patients hit plateaus, clinicians need to ask what their goals are in life, beyond the numbers. One patient with diabetes wanted to be able to attend a family wedding without having to get up in the middle of the ceremony to use the restroom, for example. “We need to help remove those barriers,” Stout said. “We need to think about how to go from a sick care system to a health and well-being system.”

Making the Shift to Population Health

Moving from a sick care system demands 5 shifts, Stout said:
  • Moving from a “healthcare system” to a “health and well-being system”
  • Changing efforts to address inequity from “doing good” to understanding that the cost of poverty and inequity is unacceptable
  • From scarcity to abundance
  • From pathology to vision—the idea that change is possible
  • From communities of poverty to communities of solution
The foundation of population health, she said, is prevention—communities and policies must support ways to create health and build it from the beginning, not try to turn a sick person into a healthy one when they turn 60. Population health must also address the country’s demographic shifts, understand the role of place in addressing equity, and embrace the importance of mental health.

Policies and health systems must be part of the solution, she said. For example, it became much easier to get people to quit smoking when public spaces became smoke-free, including hospitals. Community health must become a way of life—from community gardens to using technology remotely for mental health.

Health systems have 4 interconnected “portfolios” in their communities:

(1) Physical and mental health, which includes addressing food insecurity and social determinants of health in diabetes

(2) Social and spiritual wellbeing, which can include creation of a modified care coordinator model that creates a single coordinator for the family. Diabetes educators can be a fit for this model because they are accustomed to addressing multiple issues.  

(3) Community health and wellbeing, which can include addressing morbidities like childhood asthma with home interventions

(4) Being communities of solutions, which means using all available levers—such as engaging restaurants, local lawmakers, or environmental activists in health-related causes.

“What can we do?” Stout asked, inviting attendees to sign on to a population health framework called 100 Million Healthier Lives. “All of us can become innovators that improve health, well-being, and equity over the life course, where people live, work, learn, play, and pray,” she said. “Be a change maker. We invite you to not do it alone.”

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