Impact of a Nurse Practitioner–Led Diabetes Program on Barriers to CGM Use in a Federally Qualified Health Center After Medicaid Expansion

TL;DR

A nurse-led diabetes program helped increase CGM use in a health center after Medicaid expanded coverage, but some patient barriers like device inconvenience remained.

Contribution

This study evaluates how a nurse practitioner-led program and Medicaid expansion impacted CGM adoption and barriers in an underserved population.

Findings

40% of eligible patients were current CGM users, with non-Medicaid insurance and fewer clinic visits linked to never use.

Survey responses showed desire to reduce finger-pricks motivated CGM use, while device burden led to discontinuation.

Team-based care models helped support CGM access and sustained use in underserved populations.

Abstract

Continuous glucose monitors (CGMs) enhance diabetes management, but disparities exist, particularly among underserved populations in federally qualified health centers (FQHCs). In 2022, a California Medicaid policy change expanded CGM coverage, providing an opportunity to better evaluate barriers to CGM use within primary care in an FQHC.

We used 2022–2023 electronic health record (EHR) data to identify adults with diabetes managed on insulin within a nurse practitioner–led diabetes program in primary care. Patients were categorized as current, former, or never CGM users. We used summary statistics, chi-squared, and Bartlett's tests to assess unadjusted group differences and multivariate logistic regression to identify factors associated with former or never use. All patients were invited to complete a survey on CGM facilitators and barriers.

Among 275 eligible patients, 109 (40%) were current CGM users, 31 (11%) former users, and 135 (49%) never users. Discussions on CGM occurred in 45% of never users, who were more likely to have non-Medicaid insurance, fewer than five clinic visits (OR 3.69, 95% CI: 1.94–6.99), and a lower baseline A1C (OR 0.67, 95% CI: 0.52–0.86). No demographic or clinical factors were associated with former CGM use. Among survey respondents (n = 124), the desire to reduce finger-pricks motivated CGM use, while device burden and inconvenience contributed to discontinuation or refusal.

Medicaid policy expansion reduced major structural barriers to CGM use, yet some patient-related barriers persisted. Team-based care models integrating health educators and advanced practice providers can successfully support CGM access and sustained use in underserved populations.

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