In Detroit, A Team Care Model Increases Support for Diabetic Patients

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Health Equity

Dr. Felix M. Valbuena, Jr., CEO of CHASS, at the weekly summertime CHASS "Mercado" in 2019. The Detroit health center focuses on holistic approaches to chronic disease management, like increasing access to healthy food options. (Noah Smith/ Direct Relief)
Dr. Felix M. Valbuena, Jr., CEO of CHASS, at the weekly summertime CHASS "Mercado" in 2019. The Detroit health center focuses on holistic approaches to chronic disease management, like increasing access to healthy food options. (Noah Smith/ Direct Relief)

The saying “It takes a village” has never been truer – especially at southwest Detroit’s Community Health and Social Services Center, Inc.

When Diane Tyler-Peterson goes to the federally qualified health center (known as CHASS) for routine check-ups, she’s likely to see her doctor, pharmacist, nurse, and social worker all in one visit. Her chosen support person – her husband – is usually there too. For Tyler-Peterson, it’s helpful to have a team of people working to help her manage her diabetes.

Now, more diabetic patients will have access to the same type of team-related care, due to a grant from Direct Relief’s Fund for Health Equity.

CHASS is one of 50 recipients of grants from the fund, which was created to increase access to health care and improve health outcomes for marginalized communities. The health center, which has a longstanding and trusting relationship with Detroiters, was awarded just over $100,000 to enhance diabetic patients’ access to care coordination and medication therapy management.

Dr. Felix Valbuena, chief executive officer of CHASS, said coordinated care will help patients, medical professionals, and staff manage chronic disease together. As part of the enhanced care, pharmacists will also have more inclusive conversations with patients about medications. 

“It’s a whole team of people that are working to improve the health and wellness of that individual,” he said. “A doctor, nurse, social worker, certified medical assistant, pharmacist, outreach and enrollment officer.” 

According to Valbuena, it can be difficult for patients to get everything they need from one visit to the doctor every few months. It’s helpful to have others remind patients of their appointments, help them with eating plans, determine which medications are best and most affordable, and guide them on how often to check their glucose levels. That’s where Tyler-Peterson’s husband has an essential role to play.

“If we can leverage one more person that is part of their lives to help us avoid all of those consequences, we get one step closer to our goal in the US healthcare system where we are preventing all of these crazy diseases and all of their negative consequences,” he said.

When Tyler-Peterson was diagnosed with diabetes in 1999, she was in disbelief and didn’t plan to return to the doctor.

“I didn’t want to accept that I had it,” she said. “I just didn’t want to.”

The longtime Detroit resident said her mother had diabetes as well, eventually developing symptoms that led to amputation and partial blindness.

The medical team at CHASS warned her of the medical risks she was taking by not managing her own chronic disease, and eventually, she came around.

She reluctantly returned to the doctor and began working with CHASS, even when she didn’t have health insurance. (Federally qualified health centers treat patients regardless of their ability to pay for services.) She learned to trust her medical care team and began to listen to their suggestions for healthier living.

Valbuena says patients and their support person will receive training to manage chronic disease, while receiving an added level of preventative care. That’s unusual for CHASS patients, who often can’t afford the expenses of health care – and Valbuena said it’s why the money used to increase health equity is so important.

Mirna Robles, a nurse at CHASS, said she’s seen patients become more dedicated to managing their health conditions when they are included and educated on the details.

“It decreases the patient’s anxiety about their health,” Robles said. “I think they feel very cared for when they see that everybody is working to help them out (and) to really show that we really do care about their health.”

Over the last 22 years, Tyler-Peterson has learned how to manage her own diabetes. She relies on the CHASS care team for health protocols and her husband for at-home support. And she’s committed to working hard: She changed her diet, does a physical activity three to four days a week, and manages her daily insulin needs. Tyler-Peterson says her A1C, or glucose levels, have significantly decreased and she continues to lose weight.

Tyler-Peterson plans to continue losing weight and her goal is to stop relying on insulin. That’s why she’s her doctor’s “best patient.”

“It changed my whole output and that’s why now I’m taking care of myself, because I want to live and not die early like I was supposed to,” she said. 


Olivia Lewis is a journalist based in Detroit, Michigan.

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