How a New Pharmacist-Led Diabetes Support Program is Filling the Gap Between Appointments

I’ve lived with type 1 diabetes for much of my life. I know what it feels like to leave an appointment with a new plan, good intentions, and a long stretch of time before anyone checks in again. A lot can go wrong in that stretch.

That gap — the weeks between appointments — is where chronic disease quietly wins.

The U.S. has made reducing poorly controlled diabetes a national health priority. We’ve named it, funded it, and set targets for it. And yet the proportion of Americans with diabetes whose blood sugar remains dangerously out of control has barely moved in over a decade. Not because clinicians don’t know what good care looks like. Not because patients don’t want to be healthy. The barriers are more systemic: medication costs, food insecurity, transportation, the sheer daily weight of managing a serious chronic condition largely on your own, and a healthcare system that’s still fundamentally built around the visit.

At Shields Health Solutions, we took a population health-focused approach and asked a straightforward question: what if the care team didn’t go quiet the moment a patient walked out the door?

That question led to the development of the Diabetes Care Coach (DCC) program. A pharmacist-driven coaching model for diabetes support, built in partnership with UMass Memorial Health around the idea that integrated, people-first care means staying present for the patient beyond the clinical encounter.

We recently published four years of real-world outcomes from that program in PLOS ONE. The results make a compelling case that the in-between appointment gap isn’t an unsolvable problem.

It’s a design problem. And it has a solution.

The Pharmacist’s Role in Diabetes Management: A Care Team That Shows Up Between Appointments

The DCC program was built on a simple premise: high-risk patients with diabetes need more than a specialist they see three times a year. They need a consistent clinical relationship that shows up between appointments, not just during them — a premise that’s core to Shields’ integrated care model.

The DCC program was built on a clear understanding of the pharmacist’s role in diabetes management: not a back-office function, but a frontline clinical relationship. Shields deploys clinical pharmacists who are fully embedded in the diabetes care team — sitting alongside the endocrinologists and nurse practitioners, working inside the same EHR, co-managing the same patients. They’re credentialed as Certified Diabetes Care and Education Specialists (CDCES), trained in medication management, continuous glucose monitoring (CGM) data interpretation, nutrition counseling, mental health referral, and the social drivers that so often sit underneath uncontrolled diabetes: food access, housing instability, transportation barriers. When a patient shows up to a coaching session struggling, their coach already knows the full picture.

The cadence is intentional. Weekly telehealth sessions in the first one to two months (the highest-risk window), then biweekly as patients stabilize, always adjusted to clinical need. Sessions run up to an hour at the start and scale back to 30 minutes as the relationship matures and the patient gains confidence in managing their between-appointment care. The coach-to-patient ratio is capped at a manageable figure to allow our Coaches to build deep clinical relationships with the individuals under their care.

Telehealth for Diabetes Self-Management: What Four Years of Real-World Data Shows

We now have four years of outcomes data to show what our telehealth for diabetes self-management DCC model produces.

The study, published in PLOS ONE in March 2026, followed 239 patients enrolled in the DCC program — all of them with uncontrolled blood glucose levels, mean A1c of 10.3% — and matched them against 815 peers receiving usual specialty diabetes care at the same clinic. Same patient population. Same clinical setting. The only difference was the coaching.

The results were consistent across every metric we measured, and they pointed in the same direction.

Better Patient Outcomes

The average A1C reduction among coach-supported patients was 1.5 — a result that outperforms the typical outcomes seen in randomized controlled trials of coaching interventions. For a population this hard to move, that’s meaningful. But the numbers that tend to get a health system leader’s attention are the utilization figures. For every 100 patients enrolled in the DCC program, there were approximately 15 fewer emergency department visits, 22 fewer hospital admissions, and 3.7 fewer total hospital days compared to matched peers over one year.

Proven Financial Results

Then there’s the cost picture. Among accountable care organization (ACO) enrolled patients, the DCC program was associated with a mean reduction of $2,649 in annual total medical expenditure per patient — nearly identical to the program’s operating cost of approximately $2,800. And when you factor in the specialty pharmacy revenue generated by improved medication adherence, the program delivers a positive return-on-investment (ROI)

A care model that improves outcomes, offsets its own costs, and drives positive ROI changes the conversation from “can we afford this” to “can we afford not to.”

Where Care Coordination Ends — And Shields Begins

The subgroup analysis tells the most important part of this story.

When we broke the results down by ACO enrollment, a clear pattern emerged. The DCC program’s strongest effects showed up in patients without existing care management infrastructure. In that group, DCC enrollment was associated with 5.2 fewer hospital days per patient over one year and significantly lower 90-day readmission rates. Among ACO patients who already had a layer of coordination support in place, the incremental gains were smaller, which makes sense. The DCC model was designed to fill gaps, and ACO patients simply had fewer of them.

These are patients who fall into the gaps. Not because their care team isn’t trying, but because the demand on clinical staff far exceeds what any team can realistically manage. Between specialist appointments, there’s limited bandwidth to track whether a prescription was filled, flag a concerning trend in CGM data, or catch a life stressor before it undoes months of progress. That’s exactly where DCCs step in to support.

This is where Shields is designed to operate. Building presence in the gaps that existing care management programs don’t reach. For health systems evaluating where to direct resources in an increasingly cost-conscious environment, that distinction matters. The patients driving the most avoidable utilization are often the furthest from adequate support. The DCC model was built for exactly that population, and the data shows it.

Specialty Pharmacy as a Population Health Engine: A Diabetes Coach Model Built to Scale

From the beginning, the goal of the DCC was to build something rigorous enough to replicate — a care model with clear staffing parameters, a defined patient population, an integrated specialty pharmacy structure, and now, peer-reviewed outcomes data to back it up. The PLOS ONE publication is part of that work. It gives health system leaders something concrete to evaluate.

The financial architecture matters here, too. Roughly one-third of DCC patients were on Medicaid. The 340B drug pricing program creates a sustainable funding mechanism for exactly this population, meaning health systems that serve economically vulnerable patients aren’t looking at an unfunded mandate. The program generates the revenue it needs to run, through improved medication adherence, specialty pharmacy revenue, and 340B savings. Once patients stabilize, they transition to patient liaisons, freeing coach capacity for the next high-acuity cohort.

Health systems are under more financial pressure than they’ve been in years. Medicaid uncertainty, rising employer plan costs, and tightening margins are forcing hard conversations about where to invest. The most forward-looking health systems are already treating specialty pharmacy as a strategic lever for both revenue and outcomes. The DCC model shows what that investment can produce.

The gap between appointments has always been where chronic disease wins. The data says it doesn’t have to stay that way.

Read the full peer-reviewed study in PLOS ONE → https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0345534

To learn more about the DCC results with UMass, visit Bill’s speaking session at Asembia’s AXS26 Summit on April 27, 2026 at 3PM ET.