According to the U.S. Centers for Disease Control, more than 40 million Americans have diabetes, which is about 12% of the population. But the clinical burden of diabetes is not evenly distributed. In medically complex populations, diabetes rarely exists in isolation. It worsens cardiovascular disease, accelerates kidney disease, increases infection risk, impairs healing, and amplifies functional decline.
That reality is especially clear in the population Monogram serves. Diabetes is not simply another diagnosis on the treatment list; it is often the condition that amplifies the burden and complexity of other chronic illnesses. For these patients, diabetes management cannot be reduced to a narrow focus on blood glucose alone; instead, it must be approached in the broader context of cardiovascular, kidney, metabolic, functional, and social risk (source). As a result, diabetes treatment and care requires a lot of resources—and that care is doomed to fail if the patient does not have easy access to those resources.
That is one reason traditional, fee-for-service healthcare models often fall short. In many brick-and-mortar settings, diabetes is managed through brief, episodic visits that leave long gaps between medication changes, education, troubleshooting, and follow-up. In contrast, Monogram Health’s in-home, multi-specialty model offers the resources, education, and engagement that few other organizations can. We are redefining high touch polychronic care in this country, resulting in better care and better personal and clinical outcomes for our patients.
Offering Personal Engagement and Comprehensive Resources
Monogram’s approach is different. Our first visit is designed to be more comprehensive from the outset. We offer a 90-minute appointment to better identify not only glycemic issues, but the broader network of chronic conditions, address socioeconomic barriers to health, provide education, and prescribe medications all in one setting. This standard of care goes beyond just diagnosing and prescribing, it entails follow-up visits (typically within one week) to ensure that the patient truly understands their treatment plans and goals, feels empowered to make educated decisions about their health, as well as can take their medication properly. Monogram Health offers a 24/7 concierge-style, urgent care service staffed by physicians and nurse practitioners.
Frequent touchpoints matter because diabetes care often breaks down at the level of execution, not intention. For example, we often find that the patient is on a continuous glucose monitor (CGM), but they are not actually using it because they have either lost the reader or they do not know how to put it on. A patient may have insulin in the home, but they are using the wrong formulation, duplication therapy, or administering it ineffectively. For this reason, a medication list may look appropriate in the chart, but not match what is actually being taken in the home. When care is delivered only episodically, those problems can persist for weeks or months. When care is frequent and in the home, they can be identified and corrected in real time.
This is one of the most important aspects of Monogram’s model. Being physically in the home with the patient, their families and caregivers, allows us to assess how treatment is being carried out. We can help a patient set up various devices and we can also teach family members to do it for them. Another important differentiator of being in the home includes medication reconciliation. Studies have shown that the prevalence of polypharmacy in older patient populations dealing with polychronic conditions, especially diabetes, is close to 60%. In the home, we can look in the patient’s medicine cabinet and have a conversation on all prescriptions found and verify the patient is taking their medication correctly.
Cross Disciplinary Treatment & Care
Modern diabetes care should not be limited to glucose lowering alone. In a population where diabetes frequently coexists with chronic obesity, cardiovascular disease, kidney disease, and heart failure, treatment should reflect the broader cardio-renal-metabolic picture. At Monogram Health, when clinically appropriate, we use SGLT-2 inhibitors and GLP-1 receptor agonists not only for glycemic control, but for their added cardiovascular, kidney, and metabolic benefits. That is an important shift in how diabetes treatment is conceptualized: not simply as an A1C strategy, but as a way to reduce the downstream burden of disease.
This broader strategy works best when subspecialty support is built into the care model rather than added later through fragmented referrals. If our team already knows the patient will need multi-specialty attention —because the patient has already been diagnosed with diabetes, chronic kidney disease, elevated cardiovascular risk, COPD, behavioral health needs, or a need for palliative support —those specialists can be brought into the plan without delay. For example, If I am in a patient’s house and need a cardiologist, I can pull in our cardiologist. In turn, I also have the ability to pull in one of our social workers, our pharmacy teams, a dietitian, or our Chief Psychiatrist for a consultation around behavioral health issues. As noted by my colleagues in previous articles, our “baked-in” approach to palliative care is another key element, especially when life expectancy is lower, allowing us to lessen the burden of care by proactively coordinating a consultation with our Chief Palliative Care Specialist.
For every patient, the goal is to create a treatment plan that is clinically sound, operationally realistic, and sustainable in daily life. These treatment plans can include CGMs, GLP-1 receptor agonists, dietitian-assisted nutrition management, guideline-based blood pressure management, and coordinated specialty involvement to delay (or even prevent) organ failure, resulting in reduced hospitalizations and an improved quality of life. In the right patient, even modest early gains – including weight loss and improved adherence – can lower future metabolic risk and reduce the likelihood of hospitalization.
At Monogram, our financial incentive is tied to quality outcomes, population health, and improved patient experience.
Results
Monogram’s value-based approach means we are incentivized to make sure the patient is living their best life. That translates into better outcomes across the board for our complex patient population:
- Improved control. Among engaged patients, glycemic control improves rapidly, with A1C often reaching target within the first 3 months. In fact, we have a 92% controlled A1C level among our patients—well above the national average.
- Fewer complications. Our proactive, high touch approach also helps reduce downstream utilization, with 44% fewer admissions and 52% fewer emergency room visits among our vintage patient population.
- Better self-management. Our high-touch, high-engagement model further strengthens self-management by allowing us to quickly reinforce education, resolve barriers, and secure the resources patients and caregivers need to manage diabetes more effectively at home.
Ultimately, diabetes care fails when the treatment plan assumes resources, guidance, and follow-through that the patient does not have. It succeeds when care is frequent enough to reinforce the plan, comprehensive enough to address the comorbid burden, and practical enough to work in the patient’s real environment.
This article was published on Beckers Hospital Review on February 16, 2026.
Attributed to: Zahily Fals, M.D., Chief Endocrinologist at Monogram Health
