Background: Chronic diseases like diabetes require constant and ongoing self-management. The Health Home model provides a unique platform to facilitate diabetes management and connect patients to community resources that support and promote self-management. However, little is known about specific activities, barriers, and needs that exist in Health Homes particularly in Alabama which suffers disparately high rates of diabetes compared to other regions. To address this knowledge gap, the purpose of this study is to understand how a Medicaid Health Home facilitates diabetes management in Alabama.

Methods: Three interviewers conducted semi-structured interviews with six staff at a health home organization. A guide facilitated discussion on patient recruitment, frequency and mode of communication with patients and health care delivery team, and clinical and non-clinical patient-related barriers. Content analysis was performed to identify major themes using an iterative, combined deductive and inductive approach.

Results: Six female participants were aged a mean 49 years; majority employed 4 to 5 years in current role. Professional qualifications included a dietician, social worker, and nurses. Five care management domains were identified: health education, medication management, nutrition therapy, and addressing psychosocial issues. Facilitators of staff roles discussed were a high degree of collaboration within their organization and externally with providers and other professionals. For example, staff described the value of reciprocal relationships in which providers interacted with the health home. Barriers to care management included state Medicaid cost-sharing policies, medication limits, timely access to care, and variation in the availability of community resources.

Conclusions: These findings suggest that opportunities exist to intervene at the policy and healthcare system level to improve adult diabetes management for a vulnerable population.


A.A. Agne: None. F. Mondesir: None. J.P. Shelley: None. M. Pisu: None. A. Cherrington: Advisory Panel; Self; AstraZeneca. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Consultant; Self; Novo Nordisk Inc..

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at