Care coordination among pharmacists, diabetes educators, certified pump educators, and community health workers is critical to delivering personalized, effective diabetes management. By aligning care plans with a patient’s lived experience, available data on their diabetes progression, and available community resources, this approach ensures support is not only clinically sound but also realistic and sustainable in daily life.

• People with diabetes in under-resourced communities
• People with diabetes switching to pump-based care regimen
• Providers, community health workers, educators, and pharmacists unable to coordinate care effectively

In many rural settings, diabetes care is fragmented and siloed. Primary care providers often work without regular input from pharmacists, diabetes educators, or community health workers, limiting their ability to create holistic, patient-centered care plans. Communication between care team members is often informal and conducted through phone calls, faxes, or occasional in-person meetings. Even when input is provided, longitudinal patient data is not always easily accessible across the fragmented care continuum.

Referrals to specialists are frequently delayed due to staffing shortages, long wait times, or transportation barriers. Even when referrals are made, follow-up is inconsistent, and coordination between team members is minimal. Patients transitioning to pump-based diabetes care face particular challenges in this fragmented system, as successful pump use requires close, ongoing support from a multidisciplinary team—support that is often unavailable or poorly coordinated in rural settings. As a result, care plans are often generic and fail to reflect patients’ lived experiences and longitudinal disease progression, cultural practices, dominant language, or the realities of their local environments—such as limited food access or lack of safe spaces for physical activity.

NEEDS STATEMENT:

Enable care coordination that connect clinicians, pharmacists, diabetes educators, and community health workers to deliver personalized diabetes care in rural settings.

REQUIREMENTS:

• Shared care plans and data accessible across provider types
• Training on cultural humility and local resource mapping
• Communication tools that support real-time, cross-team updates
• Fits into incentives or reimbursement models for care coordination by measuring KPIs of improved diabetes management
• Clear role definitions to reduce duplication and maximize reach
• Diabetes care plans tailored to the economic realities of the rural poor and working class

ADDITIONAL CONSIDERATIONS:

• Consider whether there is a need for community liaisons to connect providers, pharmaceutical/device companies, and local programs.
• What has allowed care coordination models to succeed in the past or in other settings? What has caused them to fail? How can these systems be built to be adapted by users?