Backgrounder: Integrating Medical and Social Care to Improve Diabetes Outcomes

Bridging the Gap: Reducing Disparities in Diabetes Care. 
2023 October. Full version available here. This backgrounder provides a summary of key lessons learned, best practices in diabetes care, and partner profiles from the eight sites engaged in the Bridging the Gap: Reducing Disparities in Diabetes Care initiative.

Enhancing Chronic-Disease Education through Integrated Medical and Social Care: Exploring the Beneficial Role of a Community Teaching Kitchen in Oregon

Tanumihardjo JP, Davis H, Zhu M, On H, Guillory KK, Christensen J. Nutrients. 2023 Oct 14;15(20):4368. doi: 10.3390/nu15204368


Lessons Learned from Social Needs Screenings in Various Healthcare Delivery Settings

Peek ME, Tanumihardjo JP, O’Neal YO, Chin MH. 
White Paper. 2023 June. Full version available here. In this white paper, authors highlight experiences from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative of how grantee organizations conduct social needs screening that best meets the needs of their patients and their organizations.

Integrating Medical and Social Care to Reduce Diabetes Inequities: Lessons from the Bridging the Gap Program

Williams JS, Walker RJ, Peek ME, Chin MH. J GEN INTERN MED 38 (Suppl 1), 1–3 (2023). doi:10.1007/s11606-022-07977-5

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Gunter KE, Tanumihardjo JP, O’Neal Y, Peek ME, Chin MH. J GEN INTERN MED 38 (Suppl 1), 4–10 (2023). doi:10.1007/s11606-022-07926-2

Cuando el acceso es la mayor barrera: La determinación de Bessie de mantenerse sana (When Access is the Main Barrier: Bessie’s Determination to Stay Healthy)

Anaya B, Suarez A, Stein R, Hernandez M. J GEN INTERN MED 38 (Suppl 1), 11–15 (2023). doi:10.1007/s11606-022-07924-4

Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?

McGrath K. GEN INTERN MED 38 (Suppl 1), 16–17 (2023). doi:10.1007/s11606-022-07922-6

Trust Dynamics of Community Health Workers in Frontier Food Banks and Pantries: a Qualitative Study

Sommers IJ, Gunter KE, McGrath, K., Wilkinson, C., Kuther, S., Peek, M.E. & Chin, M.H. J GEN INTERN MED 38(Suppl 1), 18–24 (2023). doi:10.1007/s11606-022-07921-7

“Everything in One Place”: Stakeholder Perceptions of Integrated Medical and Social Care for Diabetes Patients in Western Maryland

Saulsberry L, Gunter KE, O’Neal Y, Tanumihardjo JP, Gauthier R, Chin, MH, Peek ME. J GEN INTERN MED 38 (Suppl 1), 25–32 (2023). doi:10.1007/s11606-022-07919-1

Hospital-Based, Community Teaching Kitchen Integrates Diabetes Education, Culinary Medicine, and Food Assistance: Case Study During the COVID-19 Pandemic

Tanumihardjo JP, Davis H, Christensen J, Smith RA, Kauffman Smith S, Gunter KE. J GEN INTERN MED 38 (Suppl 1), 33–37 (2023). doi:10.1007/s11606-022-07931-5

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes

Roth SE, Gronowski B, Jones KG, Smith RA, Kauffman Smith S, Vartanian KB, Wright BJ. J GEN INTERN MED 38 (Suppl 1), 38–44 (2023). doi:10.1007/s11606-022-07920-8

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

Wang GX, Gauthier R, Gunter KE, Johnson L, Zhu M, Wan W, Tanumihardjo JP, Chin MH. J GEN INTERN MED 38 (Suppl 1), 48–55 (2023). doi:10.1007/s11606-022-07918-2

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

Tanumihardjo JP, Kuther S, Wan W, Gunter KE, McGrath K, O’Neal Y, Wilkinson C, Zhu M, Packer C, Petersen V, Chin MH. J GEN INTERN MED 38 (Suppl 1), 56–64 (2023). doi:10.1007/s11606-022-07928-0

Community Health Collaborative Facilitates Health System and Community Change to Address Unmet Medical and Social Needs in New Jersey

Tanumihardjo JP, Morganstern E, Gunter KE, Martinez A, Altschuler S, Towns C, Schwartz E, Hopkins K, Burnett J, Ricks-Stephen C. J GEN INTERN MED 38 (Suppl 1), 65–69 (2023). doi:10.1007/s11606-022-07927-1

Barriers and Strategies to Operationalize Medicaid Reimbursement for CHW Services in the State of Minnesota: a Case Study

Gunter KE, Ellingson MK, Nieto M, Jankowski R, Tanumihardjo JP. J GEN INTERN MED 38 (Suppl 1), 70–77 (2023). doi:10.1007/s11606-022-07925-3

Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy

Sherman A, Rossides A, Cantor J. J GEN INTERN MED 38(Suppl 1), 78–80 (2023). doi:10.1007/s11606-022-07930-6

Implementing the Partnership Assessment Tool for Health to Assess and Strengthen Cross-sector Partnerships: Lessons from a Federally Qualified Health Center

Turner C, Suarez A, Tanumihardjo JP, Gunter KE, Stein R, Linhales Barker S.
Journal of Health Care for the Poor and Underserved 33(4), 222-233. Dec 2022. doi:10.1353/hpu.2022.0171

Reforming Care to Address Medical and Social Needs: Lessons from the COVID-19 Pandemic to Improve Diabetes Care and Reduce Disparities

Gunter KE, Tanumihardjo JP, O’Neal YO, Czadzeck G, Peek ME, Chin MH. 
White Paper. 2022 Dec. Full version available here. In this white paper, authors highlight examples based on experiences from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative. Eight organizations within the initiative are improving access to high-quality diabetes care and reducing health disparities for vulnerable populations. We feature the activities and strategies of each grantee organization and outline critical lessons learned during the pandemic that can improve diabetes care into the future.

Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes.

Gunter KE, Peek ME, Tanumihardjo JP, Carbrey E, Crespo RD, Johnson TW, Rueda‐Yamashita BR, Schwartz EL, Sol C, Wilkinson CM, Wilson JM.
The Milbank Quarterly. 2021 Sep 1.

As They Take on Food Insecurity, Community-Based Health Care Organizations Have Found Four Strategies That Work

Tanumihardjo JP, Gunter KE, Peek ME.
Health Affairs Blog, June 23, 2021. DOI: 10.1377/hblog20210616.615098

Integrating Technology and Human Capital to Address Social Needs: Lessons to Promote Health Equity in Diabetes Care.

Tanumihardjo JP, Gunter KE, Chin MH, Kraus RN, Smith RA, de Oliveira L, Peek ME.
Journal of Health Care for the Poor and Underserved 32(2), 241-261. May 2021. doi:10.1353/hpu.2021.0061

An Emerging Model for Community Health Worker–Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia.

Crespo R, Christiansen M, Tieman K, Wittberg R.
Prev Chronic Dis 2020;17:190316. DOI:

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