What does this research mean for the field?

A high-intensity, multidisciplinary primary care model significantly improves glycemic control in high-need, high-cost patients with poorly controlled diabetes, with continuous glucose monitoring (CGM) integration providing additional benefit. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study aims to assess the impact of a multidisciplinary primary care model on glycemic control and CGM use in high-need diabetes patients.

June 7, 2026

2916-LB: Improved Glycemic Control and CGM Uptake in High-Risk Patients Using a Multidisciplinary Primary Care Model

Key Points

This study aims to assess the impact of a multidisciplinary primary care model on glycemic control and CGM use in high-need diabetes patients.
Retrospective chart review of Care Plus participants from 5/1/2024 to 4/30/2025.
Variables extracted included diabetes diagnosis, HbA1C levels, and CGM prescriptions.
Statistical comparisons of HbA1C changes stratified by CGM use were conducted.
Mean baseline HbA1C was 10.0%, reduced to 8.1%, representing a reduction of 1.9% (p<0.0001).
66% of eligible patients received CGMs, associated with an additional 1% reduction in HbA1C (p=0.058).
HbA1C reductions were greater for diabetes referrals compared to traditional HNHC (-4.4% vs -1.3%, p<0.0001).

Abstract

Introduction and Objective: As diabetes care increasingly resides in primary care, patients with severe medical and psychosocial complexity remain challenging to manage. The Care Plus clinic is a high-intensity, multidisciplinary primary care program for high-need, high-cost (HNHC) patients that was expanded to include individuals with poorly controlled diabetes (HbA1C 10%). This study evaluated the impact of the Care Plus model on glycemic control and continuous glucose monitoring (CGM) uptake in this population. Methods: A retrospective chart review of Care Plus participants from 5/1/2024 to 4/30/2025 was conducted. Extracted variables included diabetes diagnosis, baseline and last measured HbA1C, dispensed CGM prescriptions, and language preference. Comparisons of HbA1c change stratified by CGM use were performed using a difference-in-differences approach. Finally, subgroup analyses were completed to evaluate HbA1C change and CGM usage by language preference. Results: Among 120 Care Plus participants with diabetes (95% T2DM), mean baseline HbA1C was 10.0% (SD=2.9) and mean final HbA1C was 8.1% (SD=2.1), representing a mean reduction of 1.9% (SD=2.8, p0.0001). Approximately 66% of eligible patients received CGMs. CGM use was associated with an additional 1% reduction in HbA1C compared with non-use (p=0.058). Patients referred specifically for diabetes experienced greater HbA1C reductions compared to traditional HNHC referral (-4.4% vs -1.3%, p0.0001). HbA1C improvements were similar across English- and Spanish-speaking patients, though Spanish speakers were more likely to use CGM (OR 3.67, p=0.029). Conclusion: The Care Plus model effectively improves glycemic control among HNHC patients and those with poorly controlled diabetes. CGM integration may confer additional benefit across both Spanish and English language groups. Disclosure J. Valente: None. P. Johnson: Other - independent pump trainer; Current; Tandem Diabetes Care, Inc. Other - diabetes and technology interest group chair, planning committee for DIP DIPA, MDTW moderator and presenter for webinars; Current; American Diabetes Association. Other - possible support for pilot studies in the future-funding and sample; Current; dexcom. Speaker's Bureau; Current; Spotlight AQ. J. Koontz: None. N.A. White: None. L. Paredes Acosta: None. J. Xu: None. K.B. Feiereisel: None. C.O. Usoh: None.

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