DIABETES IN RURAL AMERICA
by Betty Dabney and Annie Gosschalk
SCOPE OF PROBLEM
- Diabetes mellitus was
the sixth ranking leading cause of death in 1999.78
- Diabetes is an “ambulatory-care-sensitive”
condition.77
GOALS AND OBJECTIVES
America is in the midst of an epidemic of diabetes.
Approximately 17 million Americans, 6 percent of the population, are diabetic,
with another estimated 16 million having “pre-diabetes.”1-3 Type 2 diabetes
(formerly termed adult onset or non-insulin dependent) accounts for 90 to 95
percent of all cases and is primarily responsible for the increase in
prevalence over the past 10 years. Because the U.S. population is steadily aging
and is also disproportionately increasing in high-risk groups, the prevalence
of diabetes is expected to double by 2050.4
The nation’s vested interest
in addressing this public health crisis is articulated as follows in the
Healthy People 2010 goal relating to diabetes: “Through prevention programs,
reduce the disease and economic burden of diabetes, and improve the quality of
life for all persons who have or are at risk for diabetes.”5 Those at risk
include rural Americans by virtue of their unique demographic profile.
According to the Rural Healthy People 2010 survey, diabetes was identified as
the third highest-ranking rural health concern after access and heart disease
and stroke.6 Diabetes was consistently among the top five priorities in all
four geographic regions. The South, more than the other three
regions, rated diabetes as a priority¾the second-ranked rural priority in the
South. The difference across the regions fell just short of statistical
significance.7
This diabetes section
emphasizes the following HP2010 objectives:
- 5-1.
Increase the proportion of persons with diabetes who receive formal
diabetes education.
- 5-2.
Prevent new cases of diabetes.
- 5-3.
Reduce the overall rate of diabetes that is clinically diagnosed.
- 5-4.
Increase the proportion of adults with diabetes whose condition has been
diagnosed.
- 5-5.
Reduce the diabetes death rate.
- 5-6.
Reduce diabetes-related deaths among persons with diabetes.
- 5-7.
Reduce deaths from cardiovascular disease in persons with diabetes.
PREVALENCE
Diabetes impacts every area
of society. It occurs across all racial/ethnic and socioeconomic groups, but it
is two to five times more common in African Americans, Hispanics, Native
Americans, Pacific Islanders, and Asians.8-12 The
prevalence of diabetes varies by urbanicity and
degree of rurality. In 1995, the self-reported
prevalence of diabetes in non-metropolitan statistical areas (MSAs) of the U.S. was 17 percent higher than in central
cities and 11.7 percent higher than all MSAs (3.6
percent, 3.19 percent, and 3.24 percent, respectively).13 The prevalence of
diabetes may vary significantly across different rural regions of the country.
It is generally more common in the Southeast and Southwest.12, 14-16 Migrant farmworkers, estimated at 750,000 to 5 million, are also at risk. According to two studies of this group,
diabetes rose in rank from the sixth most frequent diagnosis or reason for
physician visits in 1980 to first place in 1986-1987.17, 18
The issue of rural-urban
disparities for diabetes is quite complex. Typically, diabetes is a more
serious problem in rural areas as they adopt a more “developed” or urban
lifestyle.19-21 As the differences between rural and urban lifestyles
disappear, higher rural prevalences may reflect
differences in socioeconomic, racial/ethnic, or age status, more so than rurality per se. However, rural-urban disparities in
diabetes are more pronounced for African Americans.22
IMPACT
Diabetes was the sixth
leading cause of death in the U.S. for the year 2000, accounting for a
preliminary 68,662 deaths in 2000.23 Death rates for diabetics are two times
higher than for non-diabetics and higher for both genders and for all ages and
races.24 Diabetics are two to four times more likely to die from heart disease;
those with pre-diabetes are twice as likely to die from heart disease.3, 25
Diabetes is the leading cause of deaths from kidney disease.26
Mortality from diabetes is
not geographically uniform and follows a similar pattern to prevalence rates,
with age-adjusted death rates generally highest in the Southeast and
Southwest.27 As with prevalence, racial/ethnic differences account for much
larger differences in mortality from diabetes than rural-urban differences.28,
29
Diabetes is the sixth leading
cause of hospitalization in the U.S. for men at least 45 years old and the
seventh overall cause for women of comparable ages.30 In 1996, diabetes
accounted for 3.8 million hospital discharges, 64 million physician office
visits, 1.2 million emergency room visits, 14 million work-loss days, and 88
million disability days.31
Diabetes also has major
consequences for virtually every system in the body that may become chronic,
debilitating, and costly to the health care system and to quality of life. Besides
cardiovascular disease, diabetes is a major risk factor for end-stage renal
disease, peripheral neuropathy, nontraumatic limb
amputations, blindness, lipid abnormalities, impotence, periodontal disease,
infections, and depression.25, 26, 32-35 The duration
of the disease is a major factor for development of complications.36-38 This is
a major concern for the increasingly younger age of onset of type 2 diabetes.
Gestational diabetes is
associated with pregnancy complications, increased neonatal morbidity and
mortality, birth defects, and increased risk for developing diabetes in both
mother and child.1, 25, 39, 40
Type 2 diabetes is closely
associated with obesity, and the sedentary, high-fat American lifestyle is
thought to be largely responsible for the epidemic sweeping the world.41
Obesity and lack of leisure activity are also more common in rural than in
urban areas.30
Other factors contributing to
development of type 2 diabetes are genetics,42-45
lower socioeconomic status,9, 11, 12, 46-49 belonging to a minority group or
the female gender, gestational diabetes, lack of early detection,50-52 acanthosis nigricans,53 and possibly exposure to certain
environmental chemicals.54-56
BARRIERS
The American health care
system has not been very effective in preventing, diagnosing, or managing
diabetes, especially in rural and low-income patients.31, 57-61 Rural residents
are less likely to visit doctors and to receive specialized care or adequate posthospital home health care.57, 62-66 Rural residence is
also a significant risk factor for never receiving an ophthalmic examination,65 which can detect early signs of diabetic retinopathy.
Other challenges to slowing the epidemic, irrespective of location, include
personal lifestyle choices relating to diet and exercise (see the Nutrition and
Overweight section).49
PROPOSED SOLUTIONS
While improving all detection
and treatment methods in rural areas is desirable, the Diabetes Prevention
Program Research Group recommends prevention as the preferable approach.67 The
onset and progression of type 2 diabetes and its complications can be delayed
or prevented by significant changes in lifestyle that are feasible to implement
in rural communities, including modest exercise and weight loss.67-69
Where prevention has not been
possible, the risk of developing complications can be minimized by effective
metabolic control, regular examinations, and patient education.25, 26, 70-72
Based on strict review of published studies, the HHS Task Force on Community
Preventive Services recommends four types of interventions for reducing
morbidity and mortality from diabetes. These are case and disease management by
health care providers, community-based self-management education programs for
adults with type 2 diabetes, and home-based programs for children and
adolescents with type 1 diabetes.73
Most published community
studies address only one component of diabetes education, prevention,
detection, and care. While many innovative programs record short-term success,
few demonstrate long-term improvement in clinical outcomes.74 New
cost-effective approaches need to be developed around a chronic disease
model,75, 76 using the existing health care and public health infrastructure,
and based upon preventive and routine patient care clustered at the community
level by allied health professionals.
Summary and Conclusions
The prevalence of diabetes is
somewhat higher in rural than in urban areas, but racial/ethnic, socioeconomic,
and lifestyle factors appear to be stronger risk factors for diabetes than
rural residence. Compounding the problem in rural areas are limited resources
to effectively diagnose and manage diabetes, reinforcing the need for an
emphasis on prevention efforts. All types of prevention have a place in
management of diabetes from a medical and public health perspective, but
primary prevention is ultimately the most cost effective and the most desirable
from an ethical standpoint. Unchecked, the diabetes epidemic will produce an
intolerable burden on the health system and quality of life over the next
generation.
MODELS FOR PRACTICE
The following models for
practice are examples of programs utilized to address this rural health issue.
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MODELS FOR
PRACTICE
FOCUS AREA: DIABETES
Program Name: Diabetes Collaborative
Location:
Laurel Health System, Wellsboro, Pennsylvania (Tioga
County)
Problem Addressed: Diabetes and Access to Primary Care
Healthy People 2010 Objective: 1-9
Web Address:
http://www.laurelhs.org; http://www.tiogapartners.org
The Laurel Health System (LHS), with its six
Federally Qualified Health Centers (FQHCs), is a
participant in a national diabetes collaborative. The
collaborative supports a systematic approach to diabetes care and management
and development of an electronic registry of patient data in the primary care
environment.
This model reflects improved access to quality
primary care addressing medical conditions (such as diabetes, hypertension, and
asthma) for which improved primary care management results in reduced
hospitalization. It includes a diabetes electronic management system that:
The model enhances clinical care enhancement and
promotes the effective use of a countywide health partnership to extend
effective prevention and primary care interventions for diabetes to other
providers and to people in the community.
Blueprint: Beginning in January 2000, LHS’s health centers were accepted for participation in the
National Diabetes Collaborative. By participating, the health centers were able
to establish a systematic approach to diabetes treatment and electronic
management of patient data. Beginning with the patients in one of the six FQHCs, the program was implemented at all six centers over
the next nine months. A key element in the program, the Diabetes Electronic
Management System (DEMS), is a registry for all Laurel Health
Center patients with
diabetes. When a patient with diabetes schedules an appointment, a DEMS report
is printed, attached to the patient’s chart, and employed by the nurse or
clinician with the patient in reviewing the patient’s condition and engaging
the patient in continuing self-management of diabetes. The registry supports
ongoing analysis of the impact of this program upon patients’ health status and
cost of treatment. This analysis is supported by IMPACT software specially
designed for organizations participating in the diabetes collaborative program.
The diabetes collaborative model, fully implemented at LHS’s
FQHCs, is currently being extended, under the
sponsorship of the countywide health partnership and regional Area Health
Education Center (AHEC), to other primary care providers in this rural county.
Making a Difference: Beginning in January 2000, the use
of DEMS and education for clinicians and office staff on diabetes management
produced immediate small improvements in diabetes outcomes. These improvements increased and
affected more patients as the program was extended to all of the six health centers
over the next nine months. The program collects the following data on patients
with diabetes: percent with HbA1c measured yearly; percent
maintaining HbA1c <8 percent, percent with annual foot exam,
percent with influenza and pneumovax immunizations,
percent controlling blood pressure at <135/85, and percent with an annual
lipid profile performed. As of April 2002, there is documentation of an average
Hemoglobin A1c (HbA1c) of 7.1 in a population of 622
diabetic patients, with an average total cholesterol
of 201 and an average LDL of 110. These factors have been demonstrated to
decrease diabetic morbidity and mortality from secondary end organ failure
(such as renal failure or heart failure secondary to diabetes). Cost savings
for averted stroke, myocardial infarction, or coronary artery bypass graft are
estimated at between $10,000 and $20,000 for each occurrence. Conversely,
primary care revenue increased as a result of the more aggressive disease
management in the first year of the program. The population of focus, 116
patients in the pre-collaborative year, yielded 115 diabetic patient visits
with a revenue of $5,410 compared to 550 visits and
$27,827 in the first year of the collaborative.
Beginnings: The
model grew out of a community needs assessment sponsored by the countywide
Tioga County Partnership for Community Health (TCPCH) in 1994. The assessment
found the self-reported diabetes rate in Tioga County
to be one-quarter higher than the national average (8 percent versus 6 percent,
nationally). The 1998 county mortality rate for diabetes at 20.2/100,000 was 45
percent higher than the state average. Beginning in 1995, patient education and
community health education components for diabetes were implemented by LHS, a
local integrated rural health system within the county. LHS’s
Laurel Health Center Diabetes Education and Nutrition Counseling program was
launched shortly after the local study. In 1996, a few providers from among the
six FQHCs began ongoing evaluation of HbA1c levels
and provision of specified care.
Challenges and Solutions: The diabetes collaborative is
associated with a northeast regional cluster of such initiatives supported by
U.S. Health Resources and Services Administration’s Bureau of Primary Health
Care. The program has become institutionalized in diabetes treatment within the
LHS FQHCs. At the same time, additional grant funding
has been attained from the Pennsylvania Department of Health by the county
partnership (TCPCH) to extend the LHS diabetes collaborative model to other
primary care providers inside the county but outside the LHS umbrella. The
success of the diabetes collaborative has led LHS to seek similar benefits for
other conditions. It recently became a participant in the national
cardiovascular collaborative.
Karen Usavage, RN, CRNP, Health Center
Administrator
Laurel Health System, Diabetes Collaborative
15 Meade
Street
Wellsboro, PA, 16901
Phone: (570) 724-5200
Fax: (570) 724-4885
MODELS FOR
PRACTICE
FOCUS AREA: DIABETES
Program Name: Delta
Community Partners in Care
Location: Clarksdale, Mississippi
Problem
Addressed: Diabetes/Hypertension
Healthy People 2010 Objective: 5, 12
Web Address: None
Delta Community Partners in Care (DCPIC) is a
coalition of 19 partners serving a 10-county rural area in the Mississippi
Delta region of northwest Mississippi.
This region’s economy is based primarily on agribusinesses associated with
raising soybeans, cotton, and catfish. This is a historically underserved area
for health care, where 29.5 percent of the population lives below poverty. Its
target population is the uninsured or underinsured between the ages of 21 and
64 who have a diagnosis of diabetes, hypertension, or both. The demographics
are 92.1 percent African American, 7.6 percent white, and 0.3 percent other.
DCPIC attempts to reduce the barriers affecting its
target population by providing outreach case management services. These
services include case management, financial assistance, transportation to
provider clinics for assistance, referral and follow-up of social issues
presenting barriers to a patient’s response to care, individualized health
education/self-care planning, and organized support services, such as support
groups, walking groups, etc. Community health education programs are also
provided for the community residents throughout the target area.
Blueprint: DCPIC is a 501(c)(3)
non-profit organization with a Board of Directors and elected officers. The
original stakeholders are still involved in the program. The operation has
grown to include 19 collaborative partners: four hospitals, four Federally
Qualified Community Health Centers (FQHC), three rural health centers, two
state department of health districts, one mental health center, three state
agencies, and two federally funded agencies. Currently, funding is from the
Health Resources and Services Administration (HRSA), and DCPIC has an advisory
council composed of representatives from the partnership members. The lead
agency for the HRSA grant is one of the original members and an FQHC. Staff
includes five persons at the central office and a caseworker at each of the 19
clinical sites.
DCPIC uses a community-based case management model to
improve the health status and risk factors in its target population.
Caseworkers are trained social workers, nurses, and lay health workers who work
directly with patients who have a diagnosis of diabetes, hypertension, or both.
The caseworkers use a holistic approach, and the environment is such that the
caseworkers and patients are able to learn from each other. As required by HRSA
funding, they use several prevention indicators: reminders for doctors to
perform foot checks, Hemoglobin A1c (HbA1c) tests every
six months, and annual eye exams.
Making a Difference: From its modest beginnings, DCPIC
has grown to provide comprehensive community-based education, prevention, and
treatment services for 1,570 patients. In this growth, they developed extensive tools and
materials for their program. A baseline survey provides a patient profile at
enrollment; all tracking and data collection forms are standardized, and
training materials have been developed for staff. Health status surveys,
knowledge assessments, health profiles, and patient satisfaction surveys are
used to gather information on the program’s success. Indicators employed not
only measure the effectiveness of the program but are also used to identify key
policy issues for change. These indicators are decreases in multiple clinic
utilization, emergency services utilization for primary care, the number of
nights hospitalized, and the amount of sick and bed days; an increased
knowledge of high blood pressure and diabetes, an increased utilization of
primary care, health status changes, better blood pressure and sugar control,
patient satisfaction, and improved overall health. The University of Mississippi Research Institute of Pharmaceutical Sciences
provides ongoing statistical analysis and outcomes assessments.
In their Final Outcome Evaluation in 1999, prepared
by the University of Mississippi Preventive Medicine Department,
many successful outcomes were reported. Of the clients currently enrolled at
the time the data were collected, emergency room utilization in the past year
had decreased significantly from 1.01 visits to 0.65 from time of entry into
the program to the time of the study. The number of outpatient visits in the
last year decreased from 0.68 to 0.31; and of the patients hospitalized in the
past year, the number of nights stayed decreased as well from 6.37 nights to
3.40. The number of sick days in the past year also declined, dropping from
26.74 days to 15.77. Not only did the physical health of the enrollees seem to
improve but their knowledge of their conditions did as well. Knowledge of both
hypertension and diabetes increased significantly, corresponding with an
increase of the patients’ ability to control their own blood pressure and blood
sugar. A new study is currently being planned comparing patients who have been
in the program since its inception to newer patients, for the 21 to 64-year-old
age group.
Beginnings: DCPIC
began as a vision of the Northwest Mississippi Regional Medical Center (NWMRMC)
in Clarksville,
from concerns in the local medical community. Greater than expected numbers of
patients were presenting in the emergency rooms or were found to have
previously undiagnosed diabetes, were suffering strokes, or were requiring
amputations. Young patients were also developing hypertension and strokes. The
uninsured and underinsured chronically ill population faced many barriers in
accessing health care services that resulted in poor health outcomes. Community
meetings were held to identify these barriers as well as other existing
problems within the health care systems.
It was originally a grassroots operation involving
four hospitals, one community health center, three state agencies and three
rural health centers, to serve a five-county area. DCPIC received a planning
grant from the W.K. Kellogg Foundation for the period from May 1, 1994, through
April 30, 1995. The planning committee consisted of representatives from
NWMRMC, health care providers within a 15 to 30-mile radius of NWMRMC, and the
Mississippi Division of Medicaid. During the planning stage, meetings were held with providers in each county. The planning was implemented in
1996, and funding ended in 1999. DCPIC had a HRSA Community Access Program
(CAP) grant for evaluating sustainability.
Challenges and Solutions: Initial funding ended in 1999, creating a challenge to
program continuation. DCPIC is brought to the attention of potential funders through presentations at state and national
conferences as well as in published articles. Funding is continuously being
sought; however, the program has maintained its focus.
Lela Keys
Delta Community Partners in Care
P.O. Box 1218
Clarksdale, MS 38614
Phone: (662) 624-3484
Fax: (662) 624-3203
E-mail: lbkeys2@bellsouth.net
MODELS FOR PRACTICE
FOCUS AREA: DIABETES
Program Name: Holy Cross
Hospital Diabetes Self-Management Program
Location: Taos,
New Mexico
Problem Addressed: Diabetes
Healthy People 2010 Objective: 5
Web Address:
http://www.taoshospital.org
The Holy Cross Hospital (HCH) Diabetes
Self-Management Program (DSMP) is a participant in the NMMRA (New Mexico
Medical Review Association) Diabetes Collaborative. HCH DSMP offers four
curriculum visits covering 15 content areas from the National Standards and an
integration of community specialists, at no cost to the patients, to provide a
weekly exercise class, bimonthly coping skills education, a monthly diabetes
support group, and annual foot exams. HCH DSMP also has an electronic patient
registry using the DEMS-Lite software. Currently, the
Diabetes Self-Management Program at Holy
Cross Hospital
can offer 100 percent access to quality diabetes education and support
regardless of an individual’s ability to pay.
Blueprint:
Susan Kargula, RN, MSN, CDE (Certified Diabetes
Educator) began the Diabetes Self-Management Program in 1992 at Holy Cross
Hospital as one of the hospital’s community wellness programs. HCH DSMP serves
the rural area in northern New Mexico, which
encompasses Taos County (population size 26,556, population
density =12) and several surrounding smaller rural areas such as Penasco, Questa, and Angel Fire. It is estimated that 2,586
individuals within the community have diabetes, and the ethnicity of the target
population is predominately Hispanic (66.3 percent) and white. HCH DSMP offers
four curriculum visits and follow up as necessary in
an individual and group setting for adults with type 1, type 2, and gestational
diabetes. The four curriculum visits cover the 15 content areas from the
National Standards: “diabetes overview and initial assessment; blood glucose
monitoring and use of results; medications; nutrition; exercise and activity;
stress and psychosocial adjustment; family involvement and social support;
relationships among nutrition, exercise, medication, and blood glucose levels;
prevention, detection, and treatment of acute and chronic complications; foot,
skin, and dental care; behavior change strategies; goal setting and risk factor
reduction; problem solving; benefits, risks, and management options for
improving glucose control; preconception care, pregnancy, and gestational
diabetes; and use of health care systems and community resources.”
Grant awards have made it possible for weekly
exercise classes, bimonthly coping skills education, a monthly diabetes support
group, and annual foot exams to be offered to patients at no cost by a
community specialist. These community specialists include a medical director,
exercise physiologist, stress reduction specialist, and certified pedorthist (a trained professional who specializes in
designing or modifying footwear to alleviate problems associated with injury or
disease¾such
as diabetic foot). To be considered for the program, patients must have written
referrals through their primary care physician. If self-referred, a DSMP staff
member assists the individual in obtaining a written referral prior to the
initiation of services. The HCH DSMP staff also obtain
registration information, insurance prior authorizations, Medicare coverage,
and ensure coverage for uninsured patients through grants and hospital in-kind
donations. The education portion of the program is either provided
individually, or in some cases, in a group setting (exercise and stress
reduction classes).
Making a Difference: As a participant in the NMMRA
Diabetes Collaborative, HCH DSMP has a strong quality improvement plan. Also, HCH DSMP has an electronic
patient registry using the DEMS-Lite software. The
DEMS-Lite patient registry is used to identify
patients, proactively manage their care, and track outcomes for the population.
The program’s current goals include: Hemoglobin A1c
HbA1c < 7.0 percent, LDL cholesterol < 100 mg, documented
annual retinal eye exam, documented annual micro albumin, and documented annual
sensory foot exam. The outcomes are tracked electronically, and annotated run
charts are reviewed and posted monthly. In the prior 12 months, HSH DSMP
recorded 869 participant visits. The participant distribution was 93 percent
type 2, 6 percent type 1, and 1 percent gestational diabetes.
HCH DSMP’s overarching goal
has been to transfer financial responsibility for education and management from
the individual patient to public resources. In the long-term, providing “free”
care for such services is not fiscally sound, nor does it ensure the viability
of the program. It will also diminish public motivation to politically assist
DSMP in achieving payment from governmental resources.
The program’s goal to provide 100 percent access to
excellence in diabetes management and support will be reached by the following
routes:
The program is presently in the planning stages of
providing a diabetes support group (as funded by grant monies). In addition,
because greater than 30 percent of the population is uninsured, the program is
in the planning stages of developing a prescription assistance program that
will provide patients with diabetes medications at no cost. Collaborating with
the hospital discharge planning team, organizers are developing an inpatient
diabetes education referral and education checklist to ensure that all patients
admitted to Holy Cross Hospital
with a primary or secondary diagnosis of diabetes will receive basic education
and support before discharge.
Beginnings: What became the Diabetes
Self-Management Program grew out of the current director’s pursuit of her
Masters of Science in Nursing degree when she was
granted a mentorship with a certified diabetes educator in 1992. She began to
imbed this education into the HCH community wellness programs, with the goal of
preventing diabetes complications in Taos
County and surrounding
areas. She began the diabetes education program at HCH the same year, initially
offering the program on lunch hours at the hospital library with no source of
funds.
Challenges and Solutions: Additional support for the program
was garnered through establishment of a fee schedule for the program in 1998.
More important, by obtaining an American Diabetes Association “Certificate of
Recognition” in 2001, the diabetes education program became eligible for
Medicare reimbursement. Such recognition increased opportunities to obtain
grants to provide coverage to uninsured individuals with diabetes. The combined
effect was to enable the program to acquire its own space and to assume
responsibilities for registration and processing of charges for education.
Currently, HCH DSMP can offer 100 percent access to
quality diabetes education and support regardless of an individual’s ability to
pay. This excellent outcome was made possible through efforts to obtain the ADA
Certificate of Recognition and grants awarded in the past year, as well as
in-kind donations from the hospital. HCH DSMP has become a “central” area for
referrals from 21 Taos
area clinicians for diabetes education, resources, and support. In 2000,
Diabetes Clinical Care Guidelines were adopted by the HCH Primary Care
Committee. At that time, the certified diabetes educators requested and
were approved to order lab work at their education sessions that were
recommended within the Clinical Care Guidelines (HbA1c, annual micro
albumin, and annual lipid profile). As a participant in the NMMRA Diabetes
Collaborative, HCH DSMP has a very strong quality improvement plan.
1397A Weimer Rd.
Taos, NM 87571
Phone: (505) 751-5750
E-mail: skargula@taoshospital.org
MODELS FOR PRACTICE
FOCUS AREA: DIABETES
Program Name: White River Rural Health Center, Inc. Diabetes Collaborative
Location: Augusta, Arkansas
Problem Addressed: Diabetes and Access to Primary Care
Healthy People 2010 Objective: 5, 12
Web Address: None
The White River Rural Health Center,
Inc. Diabetes Collaborative (WRRHCDC) is a self-contained Federally Qualified
Community Health Center (FQHC) and a participant in the Arkansas Diabetes
Collaborative and the National Diabetes Collaborative. It is funded by the
Bureau of Primary Health Care (BPHC) and provides primary care and management
of diabetes and associated conditions regardless of the ability of the patient
to pay.
This model focuses on elimination of
health disparities between populations of persons with diabetes. WRRHCDC uses
continuous quality control outcome measurements based on the Cardiovascular and
Diabetes Electronic Management System (CVDEMS) software program from BPHC.
Improved clinical practices and other information are shared between sites.
This model demonstrates that a network of FQHCs can
cooperate to improve access and quality of health care for diabetics in rural
areas.
Blueprint: WRRHCDC, a 501(c)(3) non-profit
organization, is part of the National Diabetes Collaborative (NDC), which is
comprised of FQHCs across the U.S. WRRHC receives no
additional funds for the DC, but it did receive staff training from BPHC during
the first year. WRRHC covers a four-county area in east central Arkansas. This area is
highly rural, and the main economic activity is farming. WRRHC is the only
health care provider for three of the four counties, and there is only one
local hospital. There are fewer than 5,000 residents in all but one of the
communities.
While each FQHC is independent, they
share information and clinical practices. They are organized into various
levels, including state, “clusters” (regions composed of more than one state),
and nationally. Currently, there are at least four additional FQHCs participating in the Arkansas DC.
WRRHCDC provides primary care and
management of diabetes and associated conditions, regardless of the ability of
the patient to pay. It provides all primary care on-site, including laboratory
and radiology services. Staff at the WRRHCDC clinic consists of one licensed
practical nurse and one medical doctor, one or two secretaries, and sometimes a
certified nursing assistant as needed. A half-time nutritionist was recently
hired. No donated or volunteer staff are used.
Additional data entry staff will be hired as the program spreads to include
multiple physician sites.
Information on newly diagnosed
diabetes patients is entered into a diabetes patient registry. The registry is
used to track the services needed and delivered. The software is the CVDEMS
program provided by BPHC.
WRRHCDC serves all ages and also
provides perinatal services. As a FQHC, it serves all
individuals, regardless of their ability to pay. Their target population is
approximately 20 percent black, 78 percent white, and 2 percent Hispanic. Almost
half of their population is below 200 percent of the federal poverty level.
Making a
Difference: WRRHCDC undergoes
continuous quality improvement.
CVDEMS software is used to track progress, practices, and outcomes at the level
of the individual patient, specific provider, or clinic site. Data and outcomes
are reported monthly.
Specific indicators reported by each
site are percent of patients having HbA1c <9.0 percent, having
two HbA1c determinations in one year >91 days apart, blood
pressure <135/80, goal setting in self management, annual influenza
vaccination, current pneumococcal vaccination, and
annual lipid profile. Outcomes are determined monthly, by searching the
registry on the last working day of the month for all diabetic patients who
have met the criteria for the past 12-month period. The percentage of patients
meeting the goals is based on the total number of patients in the registry on
that day.
In addition to the two original
sites, two additional sites have been added, and the Collaborative expects to
add the remaining eight sites in 2002.
Beginnings: The Collaborative began in January 1998 and is comprised
of FQHCs across the U.S. The Arkansas DC originally
consisted of two sites.
Challenges and Solutions: The strategic plan of WRRHC includes
its commitment to the BHPC’s objectives of 100
percent access, 0 percent disparities. The Diabetes Collaborative is only one
of several programs at WRRHC committed to these goals. WRRHC also began
participating in the BPHC’s Cardiovascular Collaborative
in April 2001, which operates under the same principles.
So far, WRRHC
has operated the DC with no additional funding or staffing levels. Their only
source of external funding is BPHC, and WRRHC participates in as many of BPHC’s initiatives as possible. The main challenge has been
finding resources for retinal eye exams, podiatry, and other specialized
services for treatment of complications, especially for patients who are unable
to pay. These problems are ongoing. WRRHCDC is working with the Arkansas
Department of Health Diabetes Coalition and Arkansas Disease Management
Collaborative to review external funding opportunities to fund mobile services
to cover rural areas.
WRRHCDC publicizes its successes to
BPHC by participating in the latter’s initiatives. Its public relations in the
community consist of newspaper announcements, letters, and health fairs.
WRRHC feels that its participation in
the DC was instrumental in WRRHC receiving Joint Commission on Accreditation of
Health Organizations (JCAHO) accreditation in December 1998. WRRHCDC was chosen
to participate as a “high intensity” site in a three-year study by the University of Chicago, beginning in 2001. This program
is designed to enhance WRRHCDC clinicians’ ability to assist in behavioral
change in their patients, to develop better patient communication skills, to
improve patient self-management, and to continue intensive continuous quality
improvement efforts.
Stakeholders include the state
primary care association for Arkansas Community Health Centers for technical
assistance, the Arkansas Department of Health Diabetes Coalition for training
staff and developing culturally appropriate patient educational materials, county Extension
agents and local hospital dietitians for nutritional education, and University of Arkansas for Medical Sciences for
teleconferencing support.
Brenda Kennedy, RN
White River Rural
Health Center, Inc. Diabetes Collaborative
623 North
Ninth St.
Augusta, AR 72006
Phone: (870) 347-2534
Fax: (870) 347-2882
E-mail: bkennedyrn@yahoo.com