October 20, 2026
Managing diabetes is about more than medications, lab results and clinic visits.
For many people, the challenges that make diabetes difficult to manage extend beyond the exam room. Unreliable transportation, unstable housing and limited access to food can affect a person’s ability to make lifestyle changes, take medications, attend appointments, monitor blood sugar and follow other parts of their care plan. Yet until recently, healthcare organizations had limited evidence about how addressing these medical and nonmedical health-related needs — also known as contextual factors influencing health outcomes — could improve diabetes outcomes.
The SOCRATES study, led by researchers from OCHIN and the University of North Carolina, used data from OCHIN member health centers across the country to better understand how nonmedical health-related needs influence diabetes outcomes and how health centers can respond. The study drew on the experiences of both patients and health center staff, generating evidence that is both scientifically rigorous and directly relevant to clinical practice.
What we learned
Across multiple analyses, the SOCRATES team used data from over 40,000 OCHIN patient records from OCHIN Network health centers to examine common medical and nonmedical health-related needs, including food insecurity, housing instability and transportation barriers among adults with Type 2 diabetes. These analyses consistently found that people experiencing these challenges were more likely to have worse diabetes outcomes than those who did not.
Addressing a person’s medical and nonmedical health-related needs may improve diabetes outcomes, but the improvements are likely to be modest. The SOCRATES study found that eliminating food insecurity, housing instability and transportation barriers was associated with somewhat better blood sugar and blood pressure control. However, interventions focused on these needs alone are unlikely to overcome all of the challenges people with diabetes face in managing their condition.
The takeaway is not that these interventions don’t work. Rather, the findings suggest that addressing medical and nonmedical health-related needs is necessary, but not sufficient, to improve diabetes outcomes.
In other words, addressing these needs is one part of a larger solution. Patients often face multiple, interconnected challenges, so the greatest impact may come from integrating social care with clinical care, care management and other supportive services.
How health centers are addressing nonclinical drivers of health outcomes
One of SOCRATES’ most important contributions is documenting how health centers are currently addressing contextual factors influencing health outcomes.
In interviews with 73 health center staff and 24 patients across eight health centers in the OCHIN Network, researchers observed a shared commitment to identifying patients’ medical and nonmedical health-related needs and connecting them with resources. Health centers described workflows that included screening, referral, navigation and follow-up. These services were often delivered through multidisciplinary teams that included providers, care coordinators, community health workers, patient navigators, diabetes educators and behavioral health providers.
Staff and patients consistently emphasized the importance of trust, relationship building and community partnerships in addressing medical and nonmedical health-related needs. They also described how addressing these needs can help patients engage in their care, better manage diabetes and reduce the stress and instability that can affect their health.
As one patient reflected, receiving support for medical and nonmedical health-related needs helped them take charge of their own health: “They helped me and I helped myself.”
Findings point to the need for stronger data infrastructure
The SOCRATES study found that many health centers rely on a patchwork of grants, community programs and local partnerships to support and fund integration of medical and nonmedical health-related care activities. Health center staff described difficulties tracking referrals across systems, documenting outcomes and obtaining sustainable funding for services that can be essential to patient well-being.
SOCRATES researchers also found that referral activities related to these needs are not consistently captured in structured electronic health record data, making it difficult for health centers to evaluate programs, demonstrate impact and meet emerging reporting requirements.
Together, these challenges highlight that successfully integrating medical and nonmedical health-related care requires more than committed staff and community partnerships. Health centers also need systems, workflows and financing structures that support this work over time.
These findings point to the need for stronger data infrastructure, including better documentation tools, interoperable systems and payment models that support integrating medical and nonmedical health-related needs into routine practice alongside traditional medical care.
Why this matters for health centers
Community health centers have long understood that health is shaped by more than what happens during a clinic visit.
The SOCRATES study provides evidence supporting what many health center teams already know from experience: Medical and nonmedical health-related needs influence diabetes outcomes, and helping patients address those needs is a meaningful part of high-quality care. The research also suggests that these efforts are most effective when integrated into broader, team-based care that supports patients’ clinical, behavioral and nonmedical health-related needs.
For OCHIN members, these findings reinforce the value of investing in community partnerships, team-based care, screening for medical and nonmedical health-related needs, and resource navigation. The findings also underscore the importance of continuing to advocate for policies and payment structures that make this work sustainable.
Looking ahead
The SOCRATES project demonstrates how OCHIN-based research can expand our understanding of how medical and nonmedical health-related needs intersect with healthcare. Future research can help identify which approaches are most effective, how interventions can be sustained and how health centers can better measure their impact.
By building evidence grounded in real-world health center practice, SOCRATES has helped strengthen the foundation for whole person diabetes care, advancing community well-being and supporting the work OCHIN members do every day to help patients thrive.
Learn more
To learn more about the SOCRATES project and opportunities to participate in future research activities, contact the OCHIN research team.
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Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number R01DK125406. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
