Integrated Care Management to Improve Diabetes Outcomes in Refugee and Immigrant Patients (I-Care).

Refugee and immigrant patients face significant barriers to health care and are more likely to have poorly controlled chronic disease than the general U.S. population. I-Care aims to improve health equity for refugees and immigrants who face a disproportionate burden of chronic disease. Refugees and immigrants with uncontrolled diabetes and associated cardiovascular risk factors were enrolled in a care management program within an academic adult medicine clinic. The program utilized a care manager to coordinate care and services between designated primary care providers, affiliated clinical teams, and community partners. Health literacy, chronic disease parameters, and care utilization were assessed at enrollment and 8-12 months later. A total of 50 refugees and immigrants were followed for 8 to 12 months. Clinical parameters found a reduced mean HbA1c from 9.32 to 8.60 (=0.05) and reduced low-density lipoprotein mean from 96.22 to 86.60 (=0.01). The frequency of normal blood pressures was 9 (18%) at enrollment and 16 (32%) at 1 year. The cumulative frequency of emergency room visits decreased from 66% to 36% and hospitalizations from 22% to 8%. Rates of comprehensive care monitoring, including monofilament testing and one-time ophthalmology visits, increased from 60% to 82% and from 32% to 42%, respectively. Cumulative frequency of interdisciplinary support engagement with pharmacy and nutrition visits increased from 58% to 78% and from 26% to 38%, respectively. This program highlights the importance of a multidisciplinary community-engaged care model that has demonstrated improvement in quality metrics and health care costs for refugees and immigrants.