Diabetes Coach Care Program Expands Support and Improves Outcomes for Patients
The Diabetes Coach Care Program provides intensive, individualized support for people who are struggling to keep their diabetes under control. As an extension of the UMass Memorial Health Specialty Pharmacy program, it helps patients navigate medications, access financial assistance, coordinate refills and delivery, and stay connected to their care team between visits.
The program is improving outcomes for high-risk patients while supporting value-based care by helping address medication adherence, lifestyle changes, social needs, mental health concerns and care coordination.
Building on a Strong Foundation of Diabetes Education
The American Diabetes Association-recognized diabetes education program at UMass Memorial Health covers a wide range of topics, including nutrition, insulin pumps and continuous glucose monitors, prevention of complications, and physical activity. Diabetes education alone has been shown to lower A1c and blood glucose levels—similar to medication, but without side effects.
The Challenge: Uncontrolled Blood Sugars
Despite access to education, some patients continue to experience sustained A1c levels above 9%. Many high-risk individuals face ongoing challenges managing diabetes independently, including missed appointments and disengagement from their care team.
The Solution: Diabetes Care Coaching
The Coach Care Program was developed in collaboration with Shields Health Solutions to address these gaps.
Patients work with a dedicated diabetes coach who helps implement care plans developed by their endocrinologist or nurse practitioner, bridging the gap between clinical care and everyday life.
Care Coaches support patients by:
- Managing medications, including adjustments, refills, and financial assistance
- Supporting blood sugar management with personalized strategies
- Providing nutrition and lifestyle counseling
- Screening for social determinants of health and connecting patients to resources
- Collaborating with the patient’s care team
Through regular check-ins, patients set small, achievable weekly goals, celebrate progress and build confidence in managing diabetes over time.
Coaches also help patients talk through barriers that can affect diabetes management, including stress, food access, medication challenges and daily routines.
Improved Outcomes vs. Standard Care
A study published in PLOS ONE highlights the impact of the Diabetes Coach Care Program, showing measurable improvements compared with standard care. Participants experienced meaningful A1c reductions, fewer emergency department visits and hospitalizations, and lower total medical expense.
"Among patients in the accountable care organization subgroup, participation was associated with approximately $2,649 lower annual total medical expense per patient compared with matched controls," according to Samir Malkani, MD, clinical chief of the Division of Diabetes, Endocrinology and Metabolism at UMass Memorial Health.
For every 100 patients in the program, results showed 15 fewer emergency department visits, 22 fewer hospitalizations and 3.7 fewer hospital days.
Dr. Malkani said the improvements likely reflect several factors working together, including better medication adherence, stronger understanding of diabetes and support from coaches in addressing social needs that can affect health. He emphasized that some of the most important gains come from the relationships coaches build with patients between office visits, when challenges such as food insecurity, financial stress, medication access and motivation can directly affect diabetes management.
“We think it’s a combination of factors, including better adherence to medication, understanding the disease better and the coaches helping patients address unfavorable social determinants of health.”
— Dr. Samir Malkani
Dr. Malkani noted that these ongoing relationships create opportunities to understand each individual’s story and provide support that is difficult to deliver during brief office visits alone.
A New Model for Diabetes Care
The Care Coach Program, piloted by endocrinologist Dr. Richard Haas, is now available throughout the UMass Memorial Adult Diabetes Care Clinic.
“Many of our diabetes patients face multiple challenges including medication affordability, understanding and adhering to a healthy diet, or adequately monitoring their blood sugar trends. Having a dedicated care coach who remains in regular contact and works alongside people to achieve week-over-week, incremental goals has helped them feel empowered. This program has truly been a game changer for our clinic.”
— Dr. Richard Haas
The program gives coaches the bandwidth to tailor care, listen to each person’s story and support the provider’s care plan with pharmacist-led expertise in medication management, nutrition, lifestyle and motivation.