Diabetes Care for U.S. Immigrants: Why Housing Stability and Food Access Must Come First
You only have 15 to 30 minutes to discuss your diabetes health during a typical appointment with your doctor. If you’re also an immigrant who speaks English as a second language or speaks no English at all, those 15 minutes could easily be used up with the usual conversation checklist about your prescriptions, getting enough exercise, and eating more whole foods.
But the biggest factors affecting an immigrant’s health may actually be less obvious— factors like stable housing, access to food, and the ability to afford medications and testing supplies while navigating the complicated and expensive U.S. healthcare system. Immigrants to the U.S. experience a slightly higher poverty rate than U.S.-born residents at 14.6 percent and almost 20 percent are uninsured.
If this population of people with diabetes doesn’t feel comfortable discussing these issues during a doctor’s appointment—or know where to find support—their healthcare team will continue to focus on the same message during appointments.
The patient will continue to struggle with chronically high blood sugar levels and other potential concerns including high blood pressure, high cholesterol, retinopathy, neuropathy and feeling generally unwell.
Here, we’ll look at why addressing the Social Determinants of Health (SDOH) is a critical part of providing successful diabetes care to immigrants.
Take the time to ask and listen: let the patient lead this dance
“The patient has the clearest picture of what’s going on,” says Shaun Persaud, Program Director at InquisitHealth. “We just have to give them the brush to paint that picture for us so that we can see the obstacles they’re up against.”
InquisitHealth was founded by Ashwin Patel, MD, PhD, CEO, and Brijesh Patel, CTO. Their Peer Mentor Program helps people with diabetes—and other chronic conditions—improve their health by providing them with weekly mentor sessions and extensive support to address a variety of SDOH.
InquisitHealth’s paid peer mentors are people who also live with diabetes, working remotely from all over the country. They are trained in motivational interviewing and the extensive InquisitHealth system to address virtually every part of a patient’s chronic disease self-management. InquisitHealth acquires patients usually through an insurance provider (including Medicaid) or a self-insured organization that signs up to make use of their program.
Many of the patients who enroll in the program are from the Caribbean—Haiti, Jamaica, Dominican Republic, Puerto Rico and Cuba. InquisitHealth offers Spanish-speaking mentors for patients who do not speak English.
The mentors can do something the standard healthcare system cannot: weekly conversations with the patients that welcome a deeper, more detailed look at the patient’s life. Whenever necessary, mentors can send messages to the patient’s health care team to address issues concerning medications, symptoms, etc.
But their true secret of success is the ability to create an environment in which the patient is comfortable talking about the true obstacles they are facing that are impacting their health.
“Our mentors speak with patients in such a way that the patient can see them as partners to help them achieve their goals,” explains Persaud.
“Addressing a patient’s SDOH is a critical component and a major part of how our mentoring system works,” explains Persaud. “Our program is very patient-driven. We allow the patient to tell us what they need, we allow them to lead the dance, we listen and dignify their responses, letting them know that they are in charge and that we respect what they have to say…”
InquisitHealth’s mentors speak with a new patient for anywhere from 6 to 12 months. After this first year, the patient’s A1c is then reported to the program for up to an additional 24 months to identify opportunities for ongoing support.
Find the “low-hanging fruit” for a big impact on diabetes health
“There are so many low-hanging fruits that we can uncover by having non-judgemental conversations with the patient,” explains Persaud. “Telling a patient to make healthier choices isn’t [as] helpful as understanding the choices that the patient has available to them and meeting them there. It’s not about making healthy choices—it’s about even having choices.”
Persaud says there are nearly a dozen opportunities within the social determinants of health to help any patient.
“We refer to these as ‘opportunities’ for improving blood sugar levels because they have such a big impact,” explains Persaud.
Some of these opportunities include:
- Food insecurity: Is this patient worried about running out of food before they have money to buy more?
- Nutrition education: Understanding what kinds of food they have access to and working with dietitians who understand the importance of a patient’s cultural background and how important this is to their daily nutrition.
- Scheduling appointments: Preventing the back and forth phone tag by helping patients get appointments scheduled and communicate clearly with their healthcare team.
- Other healthcare appointments: Helping patients overcome obstacles to scheduling appointments for dental cleanings, annual diabetes eye exams, kidney health, women’s health, etc.
- Medications: Helping patients secure financial assistance for medications and providing education that explains why it’s so important for their health.
- Glucose monitoring: Teaching patients how and why to check their blood sugars on a daily basis and ensuring they have access to testing supplies.
- Housing: Helping patients address housing instability and secure safe housing.
- Physical activity: Teaching patients how to incorporate more physical activity into their day while acknowledging cultural differences around exercise, physical limitations, and environmental limitations.
- Employment: Helping patients find steady, reliable employment that is near enough to home based on transportation needs.
- Insurance: Helping patients understand what their insurance plan provides and how to navigate the insurance system.
- Mental health: Helping patients with their mental health needs by explaining what is or isn’t covered by their insurance and connecting them with mental health providers.
Improving A1c by addressing food insecurity—not a diet plan
Looking at a patient’s A1c and blood pressure may lead a doctor to think they simply aren’t following through on directions. In reality, this patient may have just lost their job, can’t afford food and is about to lose their home.
Persaud offers an example of how simply addressing food insecurity can drastically improve blood sugar levels in a person with diabetes.
“This patient’s A1c was 12.2 percent at the start of the program,” explains Persaud. “Within 9 months, it was down to 8.8 percent by addressing food insecurity and helping them to take advantage of the healthier options that were available.”
The patient’s mentor quickly identified their food insecurity through InquisitHealth’s screening process and supported them through the application process for Hunger Free America. Hunger Free America helps applicants get enrolled in food assistance programs like SNAP (Supplement Nutrition Assistance Program) or WIC (for Women, Infants, and Children).
“If a patient is worried about having enough money for food or being evicted, telling them to count their carbs isn’t usually effective,” says Persaud. “When we focus on these social determinants of health, we’re looking at important factors outside of health that are affecting their daily decisions.”
InquisitHealth partners with a variety of programs like Hunger Free America to help patients address access issues to food, housing, dental care, medications and so on.
“The more we address these bigger issues, the more we see A1c levels start to decrease,” says Persaud. “We start at the beginning, and we follow through on a weekly basis.”
A patient’s culture is also a critical detail to acknowledge when it comes to food—and it often isn’t acknowledged in standard healthcare.
“If you’re working with a patient whose diet culture includes a lot of starchy plantains and cassava, you cannot just tell them to start eating whole wheat bread—that’s an entirely different diet,” says Persaud.
Instead of prescribing the standard American diet recommendations, InquisitHealth mentors start the nutrition conversation with open-ended questions.
“What are you going to have for dinner tonight?” poses a question that offers zero judgment, and gives you a glimpse at the patient’s food culture, food access and personal preferences.
Instead of telling the patient to remove entire types of food from their diet—which are often core parts of their culture—they talk about simply increasing the non-starchy vegetables on your plate while still enjoying smaller portions of the starchier choices.
“The typical healthcare team is stretched so thin on time that they can’t have that same extensive conversation,” explains Persaud. “By having this weekly touchpoint with a mentor, we get to dig deeper, and we find these opportunities hiding right below the surface.”
The bottom line…
InquisitHealth’s success in supporting the U.S. immigrant population is a much-needed reminder that simply offering standard healthcare isn’t enough.
Only by looking at the big picture of a person’s life can we ensure they have the stability that so many of us take for granted. That stability affects every decision we make throughout any given day, making a huge impact on our diabetes health.
Disclosure: Ginger Vieira previously worked as a freelance consultant and coach for Inquisit Health.