Rina Ramirez, MD, co-authors new paper on impact of Direct Relief and BD grant program 

The U.S. health care system continues to lag behind peer nations, largely due to disparities in access for low-income people and people of color. Diabetes, which affects 1 in 7 adults, highlights this gap: non-white patients and those with incomes below three times the federal poverty level face significantly higher rates of the disease.

Effective diabetes care goes beyond doctor visits and prescriptions. Patients also need access to nutritious food to follow recommended treatment plans, transportation to get to and from medical appointments, affordable medications, and stable housing to manage their conditions. Factors like these, known as social determinants, or drivers, of health (SDOH), shape whether people can stay healthy.

Traditionally, funders provide limited resources for addressing the SDOH. A new study co-authored by Zufall Health Chief Medical Officer Rina Ramirez, MD, in the Decmeber 2025 edition of Dialogues in Health demonstrates the impact of a broader approach.

In 2020, Direct Relief, supported by Becton, Dickinson and Company (BD), awarded grants to six community health centers, including Zufall, through the Helping Build Healthy Communities program. Unlike typical grants, this program encouraged clinics to address patients’ non-medical needs.

Zufall used the funding to expand home monitoring care for at-risk patients who lacked access to equipment like blood glucose kits and blood pressure cuffs. Funding also supported Zufall’s clinical pharmacy team in tailoring care to each patient’s needs and providing education and online assistance in multiple languages.

“This was a game-changer for our diabetes patients, especially during COVID when people didn’t feel comfortable coming to an office,” said Rina Ramirez, MD, Zufall’s Chief Medical Officer and co-author of the new paper published in the journal Dialogues in Health. “We could meet patients where they were and help those facing the most obstacles.” Other health centers used tactics like community health workers, behavioral health integration, and medication deliveries.

Among nearly 1,400 patients studied, hbA1C (average blood sugar over a 3-month period) dropped by 1.25 points—a reduction linked to significantly lower risks of diabetes complications and death. Patients with the most SDOH challenges—five or more needs—started with the highest blood sugar levels, showing how much these real-life barriers matter.

The study demonstrates that funding programs addressing both medical and practical needs lead to measurable health improvements. The authors hope this research guides clinic leaders, philanthropic funders, and government agencies to integrate social determinants of health into care for vulnerable populations.

For more information, see the full journal article, “Impact of philanthropic investment on integrating social determinants of health into diabetes care at US federally qualified health centers,” here.