Like most pharmacists, Julie Valdes used to recommend medication based on a patient’s diagnosis. But for those with uncontrolled diabetes, the approach wasn’t working. Despite giving them the best medications available, they kept returning with high blood sugar levels.
It “kind of forced me to say, ‘You know what, medications aren’t number one. The person as a person is number one’,”said Valdes, who works as a clinical pharmacist at Zufall Health Center in Dover, New Jersey.
Now, when she meets with a patient, she begins with a series of questions, seemingly unrelated to diabetes: “Where do you work? Where do you live? Do you have appliances in your home?” These questions help Valdes get a better understanding of what kind of medication regimen will be best for the patient, given their circumstances. If they don’t have a fridge at home, for example, temperature-sensitive insulin is not going to be an effective treatment, despite being the “gold standard” in diabetes care. “You can’t always just go by the book. You have to go by where [the patient is] at, what they’re willing to do, what is in their capacity to do.”
Valdes spends up to an hour with patients – far longer than the typical 15-minute provider visit – identifying barriers to getting patients’ diabetes under control.
Most of the time, it’s money. “I would say poverty or socioeconomics is probably the number one risk factor for diabetes,” she said.
Some patients simply can’t afford their diabetes medication. Other times, socioeconomic troubles make it difficult for patients to live a healthy lifestyle, particularly when it comes to diet. “If you make minimum wage or less, think about the quality of food you can buy,” said Valdes. Many of her patients are financially strapped, often forced to choose between paying utilities and buying groceries. “A loaf of wonder bread, like cheap white bread, is a dollar. To get whole grain bread is $4. So if you only have $10, are you going to buy the white bread or the wheat bread?”
The Right Approach
The health center provides patients with bags of food, grocery store gift cards, and information on how to access the local food pantry. This combined with education on nutrition, which Valdes provides as a certified diabetes educator, has helped patients achieve dramatic results – one patient reduced their A1C score, a measure of blood sugar over a three-month period – by three hundred percent.
Still, other patients just don’t have the time to take their medication. Valdes has patients who work 12-hour shifts and can’t get a break to inject their insulin. For these patients, she prescribes a once-daily oral medication that’s easier for them to take on the job. “The drug they’re actually willing to swallow and take, that’s the drug that’s going to work,” even if that means taking a drug that’s technically less effective. “We can have another medication that is double the efficacy…but if they’re never going to take that, [then] having the drug that’s only half as good that they’re going to take a hundred percent of the time, that’s the medication for them.”
Valdes also works with patients to overcome “preconceived notions” about diabetes medication. “In my population, insulin is the number one feared thing,” said Valdes. “They said, ‘Oh, my grandma started insulin and then a month later she lost her leg’ or, ‘I Googled insulin or I Googled Metformin and it says it breaks your liver.’” Though these side effects have not been proven, all drugs have effects, says Valdes and “a lot of times the risk of uncontrolled diabetes is way worse.”
But some patients need more than just a tailored medication regimen. For many, psychological struggles are the main barrier to achieving good health.
“If you don’t have good mental health and you’re not in the right space, you’ll never be able to implement all the dietary things, taking your medication on time. It requires like a lot of organization and a lot of self-care,” said Valdes.
That’s where the health center’s social workers come in. “A lot of our patients have been through things that are traumatic that can increase their risk for chronic conditions,” said Sarah Aleman, a licensed clinical social worker and the director of behavioral health at Zufall Health Center. Some of her patients have experienced domestic violence, childhood abuse, or witnessed gang violence.
Research shows these types of experiences hinder a person’s ability to manage stress, making it more difficult to turn off the fight or flight response. When stress hormones are constantly surging through the body, chronic disease becomes more likely. “The hormones that are going through your body when you’re stressed can increase your sugar levels,” and over time can put someone at higher risk for diabetes, explained Aleman.
In addition, several studies have documented the link between trauma and feelings of helplessness. When someone is exposed to harm they have no way of escaping, they have a harder time removing themselves from unhealthy situations later on in life. As researcher and psychiatrist Dr. Bessel van der Kolk puts it, people become “unable to take action to stave off the inevitable.” For those with a chronic disease, this can manifest as putting off treatment or forgoing care altogether. “When people have experienced trauma, the self-image and self-esteem, the depression, can make it much harder for them to reach out for help,” explained Aleman.
Maria Menzel, a licensed clinical social worker at Zufall Health Center, notes another impact of trauma: “self-sabotage.” She has seen patients refuse to take their medication or even stop taking it after seeing improvements. Historically, this has led providers to blame or scold patients, but as Valdes found, this kind of approach has yielded poor results. Now, providers like those at Zufall Health Center, are practicing trauma-informed care.
“Trauma-informed care means assuming people have been through something and shifting from what’s wrong with this person to what’s happened to them,” said Aleman. “When we can think [about] what’s happened to them, we can get them connected to resources in a nonjudgmental way.”
For Valdes, this kind of approach represents a shift in health care. “I think as a field, medicine is learning that it’s not always the data and it’s not always the clinical trials and labs,” she said. “It’s about the person.”
Direct Relief, together with BD, has provided Zufall Health Center with a $150,000 grant to expand home monitoring diabetes care for at-risk patients by providing them with equipment and supplies, including blood glucose kits and blood pressure cuffs. The funding, part of the Helping Build Healthy Communities initiative, is also being used to deploy a dedicated care team that will tailor clinical interventions to meet the individual needs of patients and provide them with education and online assistance in multiple languages.