Team-Based Strategies Advance Cardio-Renal-Metabolic Health

Am J Manag Care. 2025;31(Spec. No. 15):SP1165. https://doi.org/10.37765/ajmc.2025.89853

The management of cardio-renal-metabolic (CRM) disorders is evolving from treating individual diseases to ensuring holistic, team-based, population-focused care, according to speakers at an Institute for Value-Based Medicine^® event in Cleveland, Ohio, on November 11, 2025. The event, which was hosted by The American Journal of Managed Care^® in partnership with Cleveland Clinic, focused on the interconnected nature of diabetes, cardiovascular disease, and kidney disease, as well as the practical considerations for improving access to care for these conditions.

Event chair Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, director of education and training in diabetes technology at Cleveland Clinic, set the stage for the discussion by describing how the field has evolved in recent years. “I started my career in diabetes, and diabetes has expanded to obesity, to kidney health, to liver health,” she said. “Now there are so many comorbidities and complications that all center around diabetes and obesity, and I could have never imagined that we would be now talking about MASH [metabolic dysfunction–associated steatotic hepatitis] and MASLD [metabolic dysfunction–associated steatotic liver disease] and kidney disease, and they’re so important regarding cardiovascular health in people with diabetes and obesity.”

Clinical Advances and Collaborative Models in CRM Care

Delving further into the importance of cardiovascular care in diabetes, Keren Zhou, MD, an endocrinologist at Cleveland Clinic, described how treatment advances have ushered in a new era of treatment. For instance, bempedoic acid has been shown to improve cardiovascular outcomes in statin-intolerant patients, including lowering their risk of cardiovascular death, myocardial infarction, or stroke.¹ Equally important, however, is understanding which interventions are not effective. “How many of you get asked about red yeast rice?” Zhou asked the audience. “I do on a pretty routine basis, and the long and short of it is it doesn’t work in comparison with rosuvastatin at 5 mg.”²

The uptake of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) has transformed the field of cardiometabolic management, Zhou said, although population-level spending needs to be considered with these costly medications. She also emphasized the importance of collaboration between cardiologists and endocrinologists to jointly optimize care for both disease states, as is done in the CardioMetabolic Health Center at Cleveland Clinic. “Even though we’re still processing some of the data from this clinic, what we have been preliminarily able to see is improved [hemoglobin] A_1c, weight, blood pressure, lipids, and adherence with pharmacologic recommendations for the management of CV [cardiovascular] disease and type 2 diabetes,” Zhou said.

Similarly, evidence-based pharmacotherapy is enabling the comanagement of diabetes and kidney disease, according to Kevin Malloy, PharmD, a clinical pharmacy specialist in endocrinology at Cleveland Clinic’s Endocrinology & Metabolism Institute. As the numbers of individuals with diabetes and chronic kidney disease continue to grow, the conditions exact a significant burden on health at the population level, necessitating improved screening and management strategies, he explained.

“When we talk about our goals of care, our biggest goal should be preserving and reducing cardiovascular risk while slowing progression of chronic kidney disease,” Malloy said. “We are treating chronic kidney disease because it is such a large risk factor for increased cardiovascular events, and we need to really marry those in how we how we treat patients, so we’re not treating these separately.”

Components of this comprehensive care model include lifestyle management, blood pressure control, lipid reduction, glycemic control, and antiplatelet therapy as appropriate. Malloy also mentioned the importance of published guidelines to inform clinicians about the optimal timing and sequence of therapeutic agents. These outline the “4 pillars” of diabetic kidney disease treatment—renin-angiotensin system inhibitors, SGLT2 inhibitors, nonsteroidal mineralocorticoid antagonists, and GLP-1 RAs—but uptake of guideline-directed medical therapies has room for improvement.³

Yet another organ implicated in metabolic disease is the liver, said Sobia Laique, MD, a gastroenterologist/hepatologist at Cleveland Clinic and director of the Multidisciplinary MASLD Clinic. Obesity and type 2 diabetes are driving the growing prevalence of MASLD and MASH, she explained, and can contribute to the liver fibrosis that ultimately predicts poor outcomes, including transplant and death.

Anti-inflammatory and antifibrotic agents can help target the mechanisms of MASH, and lifestyle changes are also key. “From natural history studies, we know that if patients start hitting a percentage total body weight loss of 10% or 15%, we definitely see MASH resolution and fibrosis regression,” Laique said. “The question just is, are patients able to sustain it? I think, overwhelmingly, the answer has been no.”

But that answer is poised to change with the advent of GLP-1 RAs such as semaglutide (Ozempic/Wegovy) and tirzepatide (Mounjaro/Zepbound). Laique highlighted particularly encouraging data emerging on tirzepatide’s effect on fibrosis improvement,⁴ although she noted it is not yet FDA approved to treat MASH. Research is ongoing to discover and test new agents targeting MASH, but in the meantime, Laique called for efforts to close the identification gap by proactively screening for MASH: “The earlier we can identify them, the better.”

Joining Laique, Malloy, and Zhou for a panel moderated by Isaacs were Rachel Stulock, PharmD, RPh, clinical coordinator of the primary care clinical pharmacy team, and Taylor Stephens, PhD, a pediatric clinical psychologist, both at Cleveland Clinic. Isaacs opened by describing Cleveland Clinic’s collaborative post–kidney transplant clinic, noting that “endocrinology goes to where the patients are” to streamline insulin management and continuous glucose monitoring (CGM) access for newly transplanted patients with diabetes.

Stulock outlined lessons from a decade of work in population health within primary care. She emphasized how experience has shaped consistent processes for data-driven patient identification, outreach, and team-based intervention, explaining that “we have a playbook…for considerations at each step.” She later detailed targeted heart failure management initiatives that rely on coordinated workflows between pharmacy, primary care, and specialty teams.

Offering a pediatric lens, Stephens highlighted the importance of early psychosocial screening and family-centered care. In pediatrics, she said, “I’ve really appreciated getting to be a part of the team that starts early on in efforts to try and catch and prevent these pieces from getting more significantly worse,” pointing to screening for social drivers of health and adverse childhood experiences as crucial for identifying long-term CRM risk.

Zhou described enterprise-level tools that nudge guideline-based prescribing—such as Epic alerts that flag patients with heart failure who are not receiving key medications. She also discussed extending subspecialty expertise to internal medicine colleagues through mini-fellowships, noting efforts to “empower our internal medicine colleagues to really think about diabetes management and how to better…adhere to guidance.”

Malloy reflected on earlier collaborative models, such as the “diabetes boot camp,” which created streamlined pathways between primary care, endocrinology, and pharmacists. He emphasized the need to replicate these models in emerging disease areas, explaining that strong interdisciplinary frameworks create “a plug and chug approach as we identify new areas like metabolic liver disease.”

Finally, Laique focused on the gaps between clinical trials and real-world access. She urged the field to confront barriers to medication affordability and adherence, stating that “we have all of these beautiful clinical trials…but where we lack tremendously is what we see happen in the real world.” She called for transparent data, implementation science, and advocacy to reduce stigma and improve access to therapies across CRM conditions.

How Technology and Policy Shape CRM Outcomes

The next speaker, Kevin Pantalone, DO, professor of medicine at the Cleveland Clinic Lerner College of Medicine, discussed uses of artificial intelligence (AI) to improve cardiometabolic health. He began with a story: His patient “JB” kept asking when he could stop taking multiple drugs, but lifestyle adjustments never stuck. That changed when Pantalone enrolled him in a clinical trial using an AI-enabled coaching platform developed with Twin Health, designed to provide real-time, personalized lifestyle support.

It's not just JB who is benefiting from the Twin Precision Treatment system, which combines CGM, activity and sleep tracking, nutrition feedback, and AI-driven recommendations. Results of a randomized study published in NEJM Catalyst by Pantalone and colleagues show that use of the system was associated with greater improvements in glycemic control, weight reduction, and quality of life compared with standard type 2 diabetes care, while also supporting a substantial reduction in glucose-lowering medications.⁵

Pantalone emphasized that the benefits extended beyond clinical metrics, as patients regained energy, mobility, and confidence in daily activities. “Leveraging AI and health coaching is going to be the future by which we help augment our outcome achievements,” he predicted. “Using medications alone has shown us that even when you have the best tools available, that alone is not going to address the problem.”

Next, Stephanie L. Ash, MSW, LSW, Esq, an endocrinology social worker at Cleveland Clinic​, and William Fryfogle, PharmD, BCPS, BCACP​, an endocrinology clinical pharmacy specialist at University Hospitals, delivered a joint presentation on practical tools for accessing medications and resources for CRM health.

Ash opened by emphasizing the real-world impact of policy changes on patient care, noting, “Being proactive is a privilege, and it’s going to be really hard for some of the most vulnerable patients in our communities to access all these amazing things that we’ve heard about.” She highlighted upcoming Medicaid changes in Ohio, including work requirements for certain beneficiaries, reduced retroactive eligibility, and co-pays up to $35 for some patients. Ash also addressed Medicare reforms, including increased Part B premiums and rising out-of-pocket maximums, warning that “an extra $20 a month is not easy…that’s somebody’s weekly food budget.”

Turning to solutions, Fryfogle outlined resources to improve medication access. He highlighted manufacturer savings programs, patient assistance programs, and health system–based assistance programs, noting, “There are multiple resources available. As long as you know what you can use and what patients might be able to fit, providers can work with their patients to find the best program for them.” Diabetes and cardiometabolic medications can require creativity to ensure access, as some programs allow coverage through alternative indications.

A final panel discussion on innovative solutions featured Pantalone, Ash, and Fryfogle, joined by Ryan Majcher, RDN, a registered dietitian at the Cleveland Clinic. Majcher noted the importance of educating patients on the real-life impacts of weight reduction “to understand that it’s more than just the number on the scale.” He also stressed the role of addressing social determinants of health, such as food insecurity, in improving overall metabolic outcomes.

Returning to the role of AI in clinical practice, Pantalone mentioned its use for documentation and note summaries. “We’re working on things like a diabetes summary, where an algorithm is applied and it tells you everything about the patient’s diabetes history on a 3x5 note card piece of paper,” he said, “so you’re taking this huge amount of information and actually making it manageable so that you can use it meaningfully to stimulate discussions with the patients.”

Ash called for policy-level changes to ensure medication availability, including patent reform and public ownership of pharmaceutical distribution chains. “In the meantime, I think we should, here at Cleveland Clinic, be looking at ways to pass along these discounts to patients,” Ash said. “We provide world-class care, but who can access it?”

Finally, Fryfogle stressed the need to make sure patients feel supported when receiving multidisciplinary care for CRM conditions. It can be difficult to do in a short clinic time slot, but, he said, “I'll push the computer to the side, and I just look at the patient. I listen to them. I have to make sure that they know that I’m paying attention, and then also give them the information that they need to know how to better advocate for themselves.”

Author Information: Ms Mattina is an employee of MJH Life Sciences^®, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

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