Addressing Basic Needs to Improve Diabetes Outcomes in Medicaid Beneficiaries

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Type 2 diabetes affects over 29 million US adults, with a disproportionate burden of disease borne by low- income populations. Effective self-management requires attention, planning, follow-through and consistent performance of multiple health behaviors to prevent negative health outcomes. For low-income individuals, though, health improvement is often superseded by the drive to fulfill basic needs such as food, housing, personal safety, and money for necessities. Having unmet basic needs overwhelms a person’s ability to maintain health behaviors. Our prior research has demonstrated that with more unmet basic needs, low- income individuals are less likely to even remember let alone act on a referral for needed health services. However, when unmet needs are resolved and/or people have a personal navigator to help, the likelihood of acting on a health referral significantly increases. Traditionally, patient navigators help coordinate care, manage disease or promote screening and preventive behaviors. We propose expanding this role to include identifying and resolving unmet basic needs, which we expect will facilitate behavior change and improve health outcomes. We will test this approach in a pragmatic randomized trial conducted in partnership with Louisiana Healthcare Connections, the largest Medicaid managed care plan in Louisiana. Specifically, we propose a multi-disciplinary, multi-method study with three aims: Using observational methods, we will examine the type and number of basic needs experienced by Medicaid members, and how those needs impact health outcomes and healthcare utilization over time by linking basic needs data with claims data (Aim 1). In a pragmatic randomized trial, we will test the effectiveness (Aim 2) and cost-effectiveness (Aim 3) of a basic needs navigation intervention compared to usual care among 500 adults (ages 18-75) with Medicaid, type 2 diabetes, and 1 or more unmet basic needs. The primary hypothesis is that intervention participants will have a greater reduction (M=0.5%) in HbA1c pre-post compared with usual care participants. Consistent with our conceptual model of the effects of unmet basic needs on health outcomes, we also will examine barriers to self-care (e.g., attention, stress, sleep), health behaviors (e.g., glucose monitoring, diet, clinical screenings) and secondary health outcomes (e.g., emergency department utilization, hospitalization, quality of life). Louisiana Healthcare Connections will identify eligible members for study recruitment and provide basic needs navigation for 6 months. The research team will recruit, enroll, randomize, and survey study participants by phone at baseline and 3-, 6- and 12-month follow up. All HbA1c data will be obtained from electronic medical records between 1-3 months pre-baseline and 12 months post-baseline to assess change. If effective and cost-effective, the intervention has an accelerated path to wide diffusion through Louisiana Healthcare Connections’ parent company, Centene Corporation, which is the largest Medicaid managed care company in the U.S., with Medicaid plans in 28 other states.