Nearly one in five American adults has diabetes. But that doesn’t mean the common condition is simple to treat or manage. Diabetes and its complications are the No. 1 cause of kidney failure, adult blindness, and lower-limb amputations. It’s also the seventh-leading cause of death in the U.S. As with so many chronic conditions, diabetes also disproportionately affects the most vulnerable in our communities, further exacerbating existing health disparities.

In a new supplemental issue of the Journal of General Internal Medicine released March 28, physicians at the University of Chicago Medicine and colleagues nationwide are publishing the results of the Bridging the Gap: Reducing Disparities in Diabetes Care Initiative, a five-year multisite initiative funded by the Merck Foundation, aimed at addressing those disparities in diabetes care and outcomes across the country. Building holistic care systems to address individual medical and social care needs — along with policy changes that affect community resources and payment systems — can improve diabetes care and management and improve health outcomes for many marginalized patient populations.

Now, as they report out the final outcomes of their five-year effort, the team is sharing what has been the most successful for improving outcomes.  First, holistic, team-based care that bridges clinic treatment to community resources. This builds a trust-based relationship between clinicians and their patients and is tailored according to a patient’s severity and needs.

Second, healthcare organizations that partner with community groups to address social factors such as food insecurity. This can expand care beyond the walls of a medical clinic and empower patients to better manage their own symptoms with community support. And finally, adjusting policy and payment systems to support and incentivize prevention and addressing unmet social needs like food access or housing improves outcomes. This reduces complications and improves overall care for patients.

Collaborators have built evidence-based holistic care systems to address diabetes care on a population level. This includes programs and partnerships to address challenges faced by marginalized communities that can increase risk of diabetes complications, such as access to healthy food and secure housing, in addition to addressing healthcare challenges for individual patients.

“Diabetes is a poster child for chronic illness,” said Marshall Chin, MD, MPH, Richard Parrillo Family Distinguished Service Professor of Medicine at UChicago Medicine. “The principles we have identified and developed with this project apply to many other diseases, and could have a dramatic effect on population health and healthcare costs.”