Use Case 1. Closing equity gaps experienced by children with type 1 diabetes

The Diabetes Center at Cincinnati Children's Hospital cares for nearly all children with type 1 diabetes (T1D) in the Greater Cincinnati region. T1D is the third most common pediatric chronic disease affecting children across all ages. Recent data, both local and national, suggest that significant and persistent equity gaps characterize T1D morbidity. These trends likely mirror those seen in other chronic disease and parallel the rise in T1D incidence in racial/ethnic minority groups. 33 Although successful treatment with insulin can curtail morbidity and mortality, T1D management is complicated; made even more complex by nonmedical barriers (eg, structural barriers such as racism and adverse social determinants of health) that affect care delivery and susceptibility to complications. Thus, as a first step, to identify and define an equity gap in our setting, the Diabetes Center extracted data from the Cincinnati Children's T1D clinical registry, which includes all patients with T1D seen at our center. The Diabetes Center team saw significant, notable variation in measures like HbA1c, emergency department visits, and likelihood of admission for diabetic ketoacidosis (DKA) by both race and neighborhood poverty. With a gap identified, Diabetes Center staff assembled an improvement team that then articulated an improvement aim. The SMART aim focused on reduction of emergency room visits among a cohort of children with T1D living in high poverty, high minority population neighborhoods. The improvement team started with approximately 20 patients within the Diabetes Center for whom disease control had proven difficult. A measurement approach was developed to track outcome, process, and balancing measures for patients during their care. The team used existing registries of patients within our electronic health record to identify patient addresses which were then linked to neighborhood variables, facilitating an evaluation of contextual factors that could potential widen (or narrow) equity gaps. The school each patient attended was identified so as to extend partnership not only with the patient and family but also with in‐school providers. An iterative approach to measurement with a delineated theory for change was depicted using a key driver diagram. Example drivers included: (1) a personalized, effective, and balanced patient‐centered treatment plan; (2) community resources leveraged to partner with families and the healthcare team; and (3) informed community prepared to support the patient and family. 34 , 35 With theory developed, the team moved into a testing phase. First, although care was provided by several professionals, including physicians, diabetes researchers, nurse practitioners, psychologists, certificated diabetes educators, registered nurses, medical assistants, and insurance advocates, the improvement team recognized the challenge of a lack of time meaningfully engaging with the patient and family. Thus, a dedicated community health worker (CHW) was employed to fill gaps between and within healthcare visits. 36 Second, the improvement team implemented a qualitative evaluation of patient perspectives of environmental, cultural, physical, emotional, community, and social factors in caregiving using CareMaps (https://atlasofcaregiving.com/). CareMaps are unique visual tools diagramming a patient's support systems providing insight into the patient's “ecosystem” of care. A critical step to outcome improvement and disparity reduction was thought to be the acknowledgement that most care is provided outside the clinic setting. A third testing example was the development of an innovation fund. Using biweekly patient case reviews, and data reports, it became apparent that financial resources were required to remove barriers faced by families. T1D care was often directly challenged by an array of competing priorities families faced. Therefore, the innovation fund was used to help families circumnavigate this range of barriers. Examples include provision of temporary hotel rooms to remove families from dangerous housing situations, ride arrangements for transportation to needed therapies and resources, emergency food vouchers, and funding for participation in diabetes‐related events such as diabetes camp. Through these equity‐oriented tests pursued to meet the stated SMART aim, and using the iterative and often nonlinear processes depicted in Figure 1, the improvement team is now seeing outcome improvements for this cohort of at‐risk patients. There is much to still learn, including how to move toward scale—more patients with T1D—and spread to other, similar conditions.