As a diabetes care coordinator, Kayla Northcutt gets to know patients on a personal level. Through one-on-one conversations, she works to understand what’s preventing them from controlling their diabetes, and often she finds it’s more complicated than not taking medication.

Transportation, housing, and food insecurity all play a role in whether a person can adhere to a strict medication regimen, eat a healthy diet, and keep their stress levels in check—important steps in controlling a chronic disease like diabetes. “If they can’t get to their doctor or they can’t get their medication, it’s definitely going to affect whether they can manage their diabetes,” said Northcutt, who works with more than 1,600 patients at HealthNet—a network of community-based health centers that serve low-income and uninsured individuals in Indianapolis, Indiana.

Most conversations Northcutt has with patients happen over the phone. During these calls, she works to identify which barriers a patient may be experiencing and connect them with the health center’s multi-disciplinary team of providers. Direct Relief, together with BD, has provided a $150,000 grant to HealthNet to expand their care team to include a dietician, pharmacist, social worker, behavioral health specialist, and Northcutt’s position as a diabetes care coordinator. The funding is part of the BD Helping Build Healthy Communities initiative and providers at HealthNet work together to address the multiple, and often interrelated barriers interfering with patients’ ability to manage their diabetes. They can teach patients how to cook a healthy meal on a budget, for example, or provide them with transportation to and from their doctor’s appointments.

Many of HealthNet’s patients struggle to afford the basics, like food, rent, and clothing. For those with diabetes, the treatment of which typically involves costly medication, high-quality groceries, and a considerable amount of time spent monitoring blood sugar levels—something patients who work 12-hour shifts can’t always do, according to Northcutt—this can mean forgoing treatment altogether. “When you’re choosing between food and medication, you’re going to choose food every time,” she said.

HealthNet’s team of providers works to make sure patients don’t have to make these kinds of choices. The health center’s social worker can connect patients with groceries, rental assistance, and even help them apply for jobs. The pharmacist is able to provide patients with discounted medications. And the dietician can teach people how to make healthy meals with inexpensive ingredients.

But it’s not just about addressing the financial barriers preventing patients from controlling their diabetes. Many also struggle with anxiety and depression, which adds “an extra layer” to their diagnosis, said Northcutt. According to several studies, mental health issues, often accompanied by histories of trauma, can attribute to low self-efficacy and make it hard for people to feel in control of their health. “Some of our patients think they’re kind of stuck. It’s not something they can reverse.”

One of Northcutt’s patients whose diabetes went undiagnosed for years now has nerve damage in his arms and legs and poor vision. When she first spoke with him, he was struggling with anxiety and depression and wasn’t interested in treating his diabetes. “His mindset was that if I can’t be like I was, and in his eyes, better, then what’s the point? I’m going to continue to smoke and eat unhealthily and do what I want to do because that’s what I want to do.” However, his diabetes, if left unmanaged, could progress even further, causing him to go blind and even lose limbs. Despite outlining these risks, Northcutt couldn’t convince him the effort was worth it. “He didn’t see the benefit of making changes to prolong his life versus just continuing to do what he was doing because the end result would be the same.”

Northcutt talked with his primary care provider and the health center’s social worker who, together, helped nudge the patient towards treatment. Eventually, he accepted a referral to behavioral health. Sometimes, said Northcutt, “it takes multiple people saying the same thing and really letting our patients know this isn’t just a check box. We really do care.”