In Camden, a coalition of people is working find the best ways to care for low-income people with highly complex diabetes. One of the newest ideas is to embed some extra help right inside the doctor's office.

 

Camden resident Dianna Jones, 68, has been living with diabetes for about a decade. She's lost most of the sight in her right eye, but has developed a few tricks to remain independent.

She can't read the dial on her insulin dispenser but listens to the clicks to figure out how much she wants to take. When Jones demonstrates her strategy, nurse Victoria DeFiglio realized that her patient's strategy isn't fool proof.

"So what if I wasn't here to tell you it's on eight? How would you do it?" DeFiglio said.

"I wouldn't," Jones said. "I'd have to get somebody to check it."

"So if no one's around, you are kind of stuck, then?"

DeFiglio's diabetes education class includes all the usual questions -- about medications and how much they cost; about sugary drinks and insurance coverage. She also asks what Jones likes to do and what she has to live for.

"I'm a mother, I'm a grandmother and I raised 32 foster children," Jones said. She also volunteers as a music tutor for elementary-age kids.

In recent months, Jones' diabetes has been out of control and her doctor asked DeFiglio to step in.

DeFiglio works for the Camden Coalition of Healthcare Providers but splits her time between two physican's offices in the city.

Keying in on patient's motivation

Program manager Nadia Ali said DeFiglio and her team often begin their work with "motivational interviewing."

"She saw the different things, the priorities, that Mrs. Jones listed, and she banked on it. I think that's huge," Ali said. "It's a really great approach because you're acknowledging what the patient is feeling and you are meeting the patient where they are at, as opposed to pushing your own agenda."

In just a few minutes, DeFiglio figured out that Jones pays $500 a month -- out-of-pocket -- for her insulin. Some months she can't afford to buy the medicine.

The prescription Jones has isn't covered by her insurance. So, helping Jones switch her Medicare coverage to a different insurance company becomes the first item on a long to-do list for the health coaches.

"Everything they need from meeting with their families and teaching their families what they should eat, to sometimes going to the grocery store together," DeFiglio said.

The team also learned that Jones has had several health scares when her insulin drove her blood sugar dangerously low.

"You're trembling and trembling and you can't stop," Jones said. "They say you can go in shock like that."

DeFiglio makes sure Jones knows how to properly gauge her blood sugar level and shows her when it's safe to take her insulin. Still, Jones is leery. She has her own rules, and they've worked — more or less — for 10 years.

"Well, I just met her," Jones said. "But, what she said makes good sense."

Eventually the two reach a compromise.

"At first she wasn't taking insulin at all when she was at that level," DeFiglio said. "Now she's going to start taking half the dose she should be taking. I think she's going to find that that's rewarding and hopefully she starts to feel better and we can get her to take whatever [dose] she should be taking."

Approach is expensive but can yield other savings

In 10 months, the team has worked with about 60 patients across two sites.

The embedded care team includes a registered nurse, two health coaches from the AmeriCorps program and the help of a licensed practical nurse. Funding from the Merck Foundation helps pay for some of the $100,000 in extra clinical support each year.

That price tag is surely more than most doctor's offices could afford on their own.

Jeffrey Brenner, who leads the Camden Coalition of Healthcare Providers, acknowledges that it's expensive.

But, he added, the program is in a research and development phase. He says it takes overstaffing to figure out how to care for "complex diabetics in a poor community."

"It's like saying we are going to land a man on the moon, but we don't want to spent too much," Brenner said.

"I think the answer is when folks like Dianna stay out of the hospital you take the money that we save with Dianna and you redistribute it," DeFiglio said.

Ali said the team has helped patients with out-of-control blood sugar regain healthy levels.

By the time the program's grant funding runs out, Ali said she hopes new state and federal health policies will begin to invest more money in prevention programs like the one in Camden.

The coalition works to identify people with diabetes who frequent the emergency room too often, and those whose illness has become hard to manage. But team members are selective about who gets the most intensive — and costly —  support.

Potential patients fill out a survey to help DeFiglio gauge who's actually ready to make health changes.

"Not everyone is at the same level," Brenner said. "If they aren't ready, we will come back to them later."

In Camden, the prevalence of adults with type 2 diabetes is nearly 13 percent, nearly double New Jersey's average.