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In the United States, economic, social, and cultural barriers impede access to optimal healthcare services for many patients. These barriers are most prominent for Black, Indigenous, and People of Color (BIPOC) communities and within rural and low-income populations. As a functional medicine practitioner, what tools and practical steps within your daily practice can help support the health journey of patients in vulnerable and underserved communities? Enhancing patient trust and community connections, advocating for greater affordability, and providing options for telehealth and after-hours appointments are all potential components of improving access to needed care for these patients. Team-based care and shared medical appointments are other potential means of delivering cost-effective and collaborative care to empower patients and improve outcomes.

Patient Trust and Supporting Health

An important research study based on in-depth interviews investigated what “access” means to some low-income families.¹ Affordability and limited availability were highlighted as barriers to care; however, a continuous relationship with a healthcare provider was noted as a means to overcoming these barriers.¹ And the importance of a consistent and supportive patient-practitioner relationship continues to be a priority for the health of patients in low-income and underserved communities.^2,3

Suggested approaches that may enhance a trusting relationship between patients and practitioners include clinical interactions that are:

• Mindful of a patient’s cultural background, primary language, traditional practices, and diet.
• Transparent about healthcare costs.
• Considerate of patients’ work schedules, especially if they work hourly and do not get paid time off.
• Focused on patient-oriented health goals that consider all elements of a patient’s story, including the financial, social, and community conditions in which they live.

Patient-centered care, health coaching, and SMAs

Team-based primary care is patient-centered and involves an array of staff who are all involved in a patient’s preventative and chronic illness care.⁴ This type of care may also improve physician-patient communication and relationships, expand healthcare access, and provide efficient delivery of essential services such as patient education and self-management support.⁵

Health coaching and patient education through shared medical appointments (SMAs) may be components of team-based care and a patient-centered approach, potentially reinforcing a supportive relationship with patients. A 2020 study investigating the impact of a community-based approach that included health coaching on patient engagement in rural and low-income adults with type 2 diabetes found that those receiving the intervention showed significantly higher Patient Activation Measure scores, meaning a higher knowledge, skill, and confidence level for self-management of their chronic condition.⁶ A 2019 nonrandomized controlled trial evaluated a digital diabetes prevention program for low-income patients that also included health coaching, an education curriculum, and peer support.⁷ Reported results indicated successful engagement of participants in the program in addition to weight loss and BMI reduction as compared to controls.⁷

SMAs offer an efficient and cost-effective approach to patient education and patient empowerment in the treatment of chronic diseases.^8-11 A 2016 review evaluating the effectiveness of SMAs among patients with overweight, obesity, or diabetes found a combination of reduced costs and improvements in care, outcomes, and patient satisfaction.¹² A 2021 study on the feasibility of a group well-child care program compared to traditional care (n=175 underserved families) reported both higher rates of recommended screenings and higher patient satisfaction with their provider.¹³ Digging deeper, a 2020 review investigated the factors that may influence the imparted education during an SMA.¹⁴ The reported factors that helped create a climate of learning included:¹⁴

• A feeling of bonding.
• Humor.
• A feeling of safety.
• Access to information.
• Time, referring to the elapsed time spent on education and extra time with providers.
• The relationship between participants and staff.
• Modeling, meaning the participants use each other as models after sharing thoughts and feelings.
• Self-regulation.

In addition, the review indicated that in the SMA setting, the healthcare provider functions as both a leader as well as a peer,¹⁴ further developing the supportive and collaborative patient-practitioner relationship. Most recently, a 2022 study reported the health benefits from a community-based SMA program that focused on nutrition and lifestyle interventions in underserved communities.¹⁵ Health-related outcomes and behaviors improved and participants valued the patient education content, the ability to spend more time on those materials, and the peer support that the group setting offered.¹⁵

Conclusion

In functional medicine, collaboration and trust between a patient and practitioner is vital to supporting a patient’s health journey. Understanding and consideration of a patient’s cultural background, primary language, traditional lifestyle practices and diet, and social and economic barriers are all components to consider when co-developing the most effective and sustainable treatment plan for chronic illness. Approaches that include group visits, health coaching, or telemedicine may become relevant options for a patient’s health strategy. They may address cost, transportation, or distance challenges in addition to offering personalized health support through a range of benefits, from community connections to frequent contact and reminders regarding patient-centered goals.

A functional medicine personalized intervention may include a range of practical and consistent steps to modify lifestyle factors and enhance a patient’s healthful habits. Learn more about how lifestyle factors such as nutrition and exercise can be modified specific to the cultural, economic, and health needs of your patients to deliver personalized, effective, and sustainable interventions to combat chronic illnesses at IFM’s Applying Functional Medicine in Clinical Practice (AFMCP).

Related Articles and Podcasts

Clinician Spotlight: Cynthia Worden, DO, on the Advantages of Telemedicine

Team-Based Care and Functional Medicine: Improving Patients’ Lives

Health Coaching as a Strategy to Enhance Your Practice

References

1. Angier H, Gregg J, Gold R, Crawford C, Davis M, DeVoe JE. Understanding how low-income families prioritize elements of health care access for their children via the optimal care model. BMC Health Serv Res. 2014;14:585. doi:10.1186/s12913-014-0585-2
2. Scheid TL, Smith GH. Is physician-patient concordance associated with greater trust for women of low socioeconomic status? Women Health. 2017;57(6):631-649. doi:10.1080/03630242.2016.1202881
3. Lazar M, Davenport L. Barriers to health care access for low income families: a review of literature. J Community Health Nurs. 2018;35(1):28-37. doi:10.1080/07370016.2018.1404832
4. Wagner EH, Flinter M, Hsu C, et al. Effective team-based primary care: observations from innovative practices. BMC Fam Pract. 2017;18(1):13. doi:10.1186/s12875-017-0590-8
5. Schottenfeld L, Petersen D, Peikes D, et al. Creating patient-centered team-based primary care; AHRQ Pub. No. 16-0002-EF. Agency for Healthcare Research and Quality. Published March 2016. Accessed June 13, 2023. https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf
6. Glenn LE, Nichols M, Enriquez M, Jenkins C. Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes. Public Health Nurs. 2020;37(2):178-187. doi:10.1111/phn.12693
7. Kim SE, Castro Sweet CM, Cho E, Tsai J, Cousineau MR. Evaluation of a digital diabetes prevention program adapted for low-income patients, 2016-2018. Prev Chronic Dis. 2019;16:E155. doi:10.5888/pcd16.190156
8. Egger G, Stevens J, Ganora C, Morgan B. Programmed shared medical appointments: a novel procedure for chronic disease management. Aust J Gen Pract. 2018;47(1-2):70-75. doi:10.31128/AFP-07-17-4283
9. Egger G, Stevens J, Volker N, Egger S. Programmed shared medical appointments for weight management in primary care: an exploratory study in translational research. Aust J Gen Pract. 2019;48(10):681-688. doi:10.31128/AJGP-05-19-4940
10.  Beidelschies M, Alejandro-Rodriguez M, Guo N, et al. Patient outcomes and costs associated with functional medicine-based care in a shared versus individual setting for patients with chronic conditions: a retrospective cohort study. BMJ Open. 2021;11(4):e048294. doi:10.1136/bmjopen-2020-048294
11.  de Lourdes Arrieta-Canales M, Mukherjee J, Gilbert H, et al. Transforming care for patients living with diabetes in rural Mexico: a qualitative study of patient and provider experiences and perceptions of shared medical appointments. Glob Health Action. 2023;16(1):2215004. doi:10.1080/16549716.2023.2215004
12.  Trickett KH, Matiaco PM, Jones K, Howlett B, Early KB. Effectiveness of shared medical appointments targeting the triple aim among patients with overweight, obesity, or diabetes. J Am Osteopath Assoc. 2016;116(12):780-787. doi:10.7556/jaoa.2016.153
13.  Friedman S, Calderon B, Gonzalez A, et al. Pediatric practice redesign with group well child care visits: a multi-site study. Matern Child Health J. 2021;25(8):1265-1273. doi:10.1007/s10995-021-03146-y
14.  Tsiamparlis-Wildeboer AHC, Feijen-De Jong EI, Scheele F. Factors influencing patient education in shared medical appointments: integrative literature review. Patient Educ Couns. 2020;103(9):1667-1676. doi:10.1016/j.pec.2020.03.006
15.  Bharmal N, Beidelschies M, Alejandro-Rodriguez M, et al. A nutrition and lifestyle-focused shared medical appointment in a resource-challenged community setting: a mixed-methods study. BMC Public Health. 2022;22(1):447. doi:10.1186/s12889-022-12833-6