"Everything in one place": Stakeholder perceptions of integrated medical and social care for diabetes patients in Western Maryland

BACKGROUND: Patients with type 2 diabetes frequently have both medical- and health-related social needs that must be addressed for optimal disease management. Growing evidence suggests that intersectoral partnerships between health systems and community-based organizations may effectively support improved health outcomes for patients with diabetes. OBJECTIVE: The purpose of this study was to describe stakeholders' perceptions of the implementation factors associated with a diabetes management program, an intervention involving coordinated clinical and social services supports to address both medical- and health-related social needs. This intervention delivers proactive care alongside community partnerships, and leverages innovative financing mechanisms. DESIGN: Qualitative study with semi-structured interviews. PARTICIPANTS: Study participants included adults (18 years or older) who were patients with diabetes and essential staff (e.g., members of a diabetes care team, health care administrators) and leaders of community-based organizations. APPROACH: We used the Consolidated Framework for Implementation Research (CFIR) to develop a semi-structured interview guide designed to elicit perspectives from patients and essential staff on their experiences within an outpatient center to support patients with chronic conditions (the CCR) as a part of an intervention to improve care for patients with diabetes. KEY RESULTS: Interviews illuminated three key takeaways: (1) team-based care held an important role in promoting accountability across stakeholders motivating patient engagement and positive perceptions, (2) mission-driven alignment across the health care and community sectors was needed to synergize a broad range of efforts, and (3) global payment models allowing for flexible resource allocation can invaluably support the appropriate care being directed where it is needed the most whether medical or social services. CONCLUSIONS: The views and experiences of patient and essential staff stakeholder groups reported here thematically according to CFIR domains may inform the development of other chronic disease interventions that address medical- and health-related social needs in additional settings.