How the Roybal Clinic Reveals the Challenges and Triumphs of Diabetes Care in Low-Income Communities
By Alasdair Wilkins
We recently visited the Roybal Diabetes Management Center in Los Angeles, a clinic for low-income adults with difficult-to-control type 2 diabetes. Roybal is unique for its team-based model and its integration of mental health care. A study has found that reductions in mean LDL and blood pressure are maintained even two years after patients leave the program.
If you want to understand the real challenges in diabetes care in the United States, then the Roybal Diabetes Management Center in East Los Angeles is a good place to start. Led by Dr. Anne Peters of the University of Southern California and Dr. Michael Roybal of the LA County Department of Health Services, the center serves low-income patients with difficult-to-control type 2 diabetes. The clinic’s visitors are typically uninsured, and many are first-generation immigrants with limited command of English. The work at Roybal illustrates why it is both so difficult and important to ensure that every person with diabetes has access to care, regardless of income level.
How does the Roybal clinic work?
The most important goal for the clinicians at Roybal is to build strong relationships with those who visit the center and to coordinate care as a team composed of nurses, nurse practitioners, endocrinologists, and a social worker.
The clinic holds a six- to nine-month treatment program with the goal of bringing A1c down to 7.0%. Patients engage in a two-hour initial appointment, half-hour individual follow-up sessions, and hour long group sessions, all designed to provide opportunities for encouragement and support from the Roybal staff.
Communication and education are crucial, and we spoke with dedicated nurses and nurse practitioners at Roybal who emphasized the importance of compassion and understanding patients’ cultural needs. Many of the nurses and nurse practitioners are fluent in Spanish, and the ability to speak to people in their preferred language can be crucial to overcoming distrust of healthcare providers.
What challenges do low-income patients face?
The rate of diabetes among people in Los Angeles living below the poverty line has skyrocketed from 9.0% ten years ago to 14.7% today. The same trend has been observed in low-income areas throughout the country, although the issue is particularly serious in immigrant populations, where language and cultural divides increase barriers to care. Misinformation is commonplace; many enter Roybal believing they “caught” diabetes from a hospital visit or that insulin will make them go blind. The Roybal staff reports that many patients are reluctant to begin insulin therapy because they fear discrimination from their employers, which can be a real concern. Additionally, many employers will not allow blood glucose testing supplies or insulin syringes at the workplace.
Many patients at Roybal simply don’t have the time to keep their families housed and fed and still get proper medical care. Long workdays and commitments at home may force people to miss appointments. About a third of Roybal patient meetings occur over the phone, and this crucial policy recognizes the limited mobility as well as the work and family responsibilities that many low-income patients must juggle.
Perhaps the Roybal clinic’s biggest innovation is the emphasis on mental health as part of the larger story of diabetes management. The staff includes a social worker that meets with patients individually to assess stress levels and possible mental health problems. Depression is common, and many people are prescribed antidepressants along with their diabetes medications. Group sessions allow people to interact with another, offering a vital reminder that they are not alone in their struggle. As Roybal social worker Ms. Cortes-Kanter observes in her introductory letter to patients, successful diabetes management requires diet, exercise, medication, and what she calls “internal peace and tranquility.”
What does the future hold?
Early results for the Roybal clinic are encouraging. Between 2007 to 2010, patients at Roybal experienced an average decline in A1c from 8.8%-11.9% to 6.8%-7.9%, along with significant reductions in LDL cholesterol and blood pressure. A smaller follow-up study suggested former Roybal patients maintained reductions in cholesterol and blood pressure after two years, but average A1c went back up to 8.3%. Roybal staffers have been working on improving A1c reductions, although they explained that many people must face extraordinary challenges to continue their regular medication schedule - some struggle to find the time for appointments to refill their prescriptions, while others take extended trips abroad where access to medication is limited. Still, the importance of even temporary improvements should not be underestimated. As the researchers for the DCCT and EDIC trials argued at this year’s ADA, an improvement in A1c today can prevent complications decades down the road, even if the reductions are not maintained long-term.
Make no mistake: the Roybal clinic is not perfect. But it is a wonderful illustration of how patients and health care providers can work together to improve the state of our nation’s diabetes care in the face of unimaginable challenges. We believe that many elements of the clinic – including team-based care and mental health support – can be scaled up and used to deliver better care to all people. As Dr. Peters said to us, “Good management is possible in just about every setting.”