Diabetes Treatments

America is in the midst of an epidemic of diabetes. economic burden of diabetes, and improve the diabetes was identified as the third highest-ranking …

DIABETES IN RURAL AMERICA
by Betty Dabney and Annie Gosschalk

SCOPE OF PROBLEM Diabetes mellitus was the sixth ranking leading cause of death in 199978 Diabetes is an ambulatory-care-sensitive condition77 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 1-3 Six percent of the pre-diabetes Type 2 diabetes formerly population are termed adult onset or diabetic, with non-insulin dependent another estimated accounts for 90 to 95 percent of all cases and 16 million having is primarily pre-diabetes1-3 responsible for the increase in prevalence over the past 10 years Because the US population is steadily aging and is also disproportionately increasing in high-risk groups, the prevalence of diabetes is expected to double by 20504 The nations 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 diabetes5 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 stroke6 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 prioritythe second-ranked rural
Diabetes in Rural America

priority in the South The difference across the regions fell just short of statistical significance7 This diabetes section emphasizes the following HP2010 objectives:5 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, Diabetes was Pacific Islanders, and identified as the Asians8-12 The prevalence of diabetes third highestvaries by urbanicity and ranking rural degree of rurality In health concern 1995, the self-reported after access and prevalence of diabetes in non-metropolitan oral health6 statistical areas MSAs of the US was 17 percent higher than in central cities and 117 percent higher than all MSAs 36 percent, 319 percent, and 324 percent, respectively13 The prevalence of

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diabetes may vary significantly across different rural regions of the country It is generally more common in the Southeast and Southwest12, 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 1986-198717, 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 lifestyle19-21 As the differences between rural and urban lifestyles disappear,
higher rural prevalences may reflect differences in socioeconomic, racial/ethnic, or The prevalence of age status, more diabetes may vary so than rurality per se However, significantly across rural-urban different rural regions disparities in of the country diabetes are more pronounced for African Americans22 IMPACT Diabetes was the sixth leading cause of death in the US for the year 2000, accounting for a preliminary 68,662 deaths in 200023 Death rates for diabetics are two times higher than for non-diabetics and higher for both genders and for all ages and races24 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 disease3, 25 Diabetes is the leading cause of deaths from kidney disease26 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 Southwest27 As with prevalence, racial/ethnic differences account for much larger differences in mortality from diabetes than rural-urban differences28, 29 Diabetes is the sixth leading cause of hospitalization in the US for men at least 45
years old and the
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seventh overall cause for women of comparable ages30 In 1996, diabetes accounted for 38 million hospital discharges, 64 million physician office visits, 12 million emergency room visits, 14 million work-loss days, and 88 million disability days31 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 depression25, 26, 32-35 The duration of the disease is a major factor for development of complications36-38 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 child1, 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 world41 Obesity and lack of leisure activity are also more common in rural than in urban areas30 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 chemicals54-56 BARRIERS The American health care system has not been very effective in preventing, diagnosing, or managing diabetes, especially in rural and low-income patients31, 57-61 Rural residents are less likely to visit doctors and to receive specialized care or adequate posthospital home health care57, 62-66 Rural residence is also a significant risk factor for never receiving an ophthalmic examination,65 which can detect early
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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 section49 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 approach67 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 loss67-69 Where prevention has not been possible, the risk of developing complications can be minimized by effective metabolic control, regular examinations, and patient education25, 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, communitybased self-management education programs for adults with type 2 diabetes, and home-based programs for children and adolescents with type 1 diabetes73 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 outcomes74 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,
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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 REFERENCES 1 American Diabetes Association ADA Diabetes Facts and
Figures, 2000 http://wwwdiabetesorg/ ada/ factsaspFebruary 28, 2001 2 ADA and National Institute of Diabetes, Digestive and Kidney Diseases NIDDK The prevention or delay of type 2 diabetes Diabetes Care 25:742-749, 2002 3 US Department of Health and Human Services DHHS HHS, ADA warn Americans of prediabetes, encourage people to take healthy steps to reduce risks Updated statistics show 17 million with diabetes, 16 million more with pre-diabetes Washington, DC: HHS Press Release, March 27, 2002 4 Boyle, JP; Honeycutt, AA; Narayan, KM; et al Projection of diabetes burden through 2050 Impact of changing demography and disease prevalence in the US Diabetes Care 2411:1936-1940, 2001 5 US Department of Health and Human Services Healthy People 2010 2nd ed With Understanding and Improving Health and Objectives for Improving Health 2nd vols Washington, DC: US Government Printing Office, November 2000
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6 Gamm, L; Hutchison, L; Bellamy, G; et al Rural healthy people 2010: Identifying rural health priorities and models for practice Journal of Rural Health 181:9-14, 2002 7 Gamm, L, and Hutchison, L Rural health priorities in AmericaWhere you stand depends on where you sit Journal of Rural
Health Forthcoming, Summer 2003 8 King, H; Aubert, RE; and Herman, WH Global burden of diabetes, 1995-2025 Diabetes Care 219:1414-1431, 1998 9 Harris, MI Diabetes in America: Epidemiology and scope of the problem Diabetes Care 21 Suppl 3:C11-C14,1998 10 Knowler, WC; Pettit, DJ, Saad, MF; et al Diabetes mellitus in the Pima Indians: Incidence, risk factors, and pathogenesis Diabetes and Metabolism Reviews 61:1-27, 1990 11 Carter, JS; Pugh, JA; and Monterrosa, A Noninsulin-dependent diabetes mellitus in minorities in the United States Annals of Internal Medicine 125:221-232, 1996 12 Sundquist, J; Winkleby, MA; and Pudaric, S Cardiovascular disease risk factors among older black, Mexican-American, and white women and men: An analysis of NHANES III, 1988-1994 Journal of the American Geriatrics Society 492:109-116, 2001 13 National Center for Health Statistics Current Estimates from the National Health Interview Survey, Series 10 No 199 DHHS Publication No PHS 98-1527 Department of Health and Human Services, Centers for Disease Control and Prevention, 1998 14 Willems JP; Saunders, JT; Hunt, DE; et al Prevalence of coronary heart disease risk factors among rural blacks: A community-based
study Southern Medical Journal 908:814-820, 1997

15 Michalek, AM; Mahoney, MC; and Calebaugh, D Hypothyroidism and diabetes mellitus in an American Indian population Journal of Family Practice 497:638-640, 2000 16 Gilliland, FD; Mahler, R; Hunt, WC; et al Preventive health care among rural American Indians in New Mexico Preventive Medicine 282:194-202, 1999 17 Hicks, W Migrant health: An analysis Washington, DC: National Association of Community Health Centers, Inc, 1982 18 Dever, GEA Migrant health status: Profile of a population with complex health problems Austin, TX: National Migrant Resource Program, Inc, Migrant Clinicians Network monograph series, 1991 19 Lerman, IG; Villa, AR; Llaca Martinez, C; et al The prevalence of diabetes and associated coronary risk factors in urban and rural older Mexican populations Journal of the American Geriatrics Society 4611:1387-1395, 1998 20 Cruz-Vidal, M; Costas, R, Jr; García-Palmieri, MR; et al Factors related to diabetes mellitus in Puerto Rican men Diabetes 284:300-307, 1979 21 Haddock, L, and Torres de Conty, I Prevalence rates for diabetes mellitus in Puerto Rico Diabetes Care 14 Suppl 3:676-684, 1991 22 Slifkin, RT; Goldsmith, LJ;
and Ricketts, TJ Race and place: Urban-rural differences in health for racial and ethnic minorities Working Paper No 66 Chapel Hill, NC: Cecil G Sheps Center for Health Services Research, North Carolina Rural Health Research Program, 2000 23 Minino, AM, and Smith, BL Deaths: Preliminary data for 2000 National Vital Statistics Reports 4912, 2001 24 Gu, K; Cowie, CC; and Harris, MI Mortality in adults with and without diabetes in a national cohort of the US population, 1971-1993 Diabetes Care 21:1138-1145, 1998
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25 Centers for Disease Control and Prevention CDC National Diabetes Fact Sheet: National estimates and general information on diabetes in the United States Atlanta, GA: HHS, 1998 26 CDC Diabetes: A serious public health problem at a glance 2001 http://wwwcdcgov/diabetes/ pubs/glancehtmMarch 2002 27 Pickle, LW; Mungiole, M; Jones, GK; et al Atlas of United States mortality Hyattsville, MD: National Center for Health Statistics, 1996 28 Ricketts, TC ed Rural Health in the United States New York: Oxford University Press, 1999, 21 29 Schorr, V; Crabtree, DA; Wagner, D; et al Differences in rural and urban mortality: Implications for health education
and promotion Journal of Rural Health 51:67-80, 1999 30 Eberhardt, M; Ingram, D; Makuc, D; et al Urban and Rural Health Chartbook Health, United States, 2001 Hyattsville, MD: National Center for Health Statistics, 2001 31 CDC Statistics - Diabetes surveillance, 1999, 2000 wwwcdcgov/diabetes/statistics/survl99/ June 2002 32 Smith SA, and Poland, GA Use of influenza and pneumococcal vaccines in people with diabetes Diabetes Care 231:95-108, 2000 33 Egede, LE; Zheng, D; and Simpson, K Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes Diabetes Care 253:464-470, 2002 34 Griffiths, RD, and Moses, RG Diabetes in the workplace Employment experiences of young people with diabetes mellitus Medical Journal of Australia 1583:169-171, 1993 35 Joachim, G, and Acorn, S Stigma of visible and invisible chronic conditions Journal of Advanced Nursing 321:243-248, 2000
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36 Florkowski, CM; Scott, RS; Coope, PA; et al Age at diagnosis, glycaemic control and the development of retinopathy in a population-based cohort of type 1 diabetic subjects in Canterbury, New Zealand Diabetes Research and Clinical Practice
522:125-131, 2001 37 Motala, AA; Pirie, FJ; Gouws, E; et al Microvascular complications in South African patients with long-duration diabetes mellitus South African Medical Journal 9111:987-992, 2001 38 Porta, M; Sjoelie, A-K; Chaturvedi, N; et al Risk factors for progression to proliferative diabetic retinopathy in the EURODIAB prospective complications study Diabetologia 4412:22032209, 2001 39 Becerra, J; Khoury, M; Cordero, J; et al Diabetes mellitus during pregnancy and the risks for specific birth defects: A population-based casecontrol study Pediatrics 851:1-9, 1990 40 Plagemann, A; Harder, T; Kohlhoff, R; et al Glucose tolerance and insulin secretion in children of mothers with pregestational IDDM or gestational diabetes Diabetologia 409:1094-1100, 1997 41 Mokdad, AH; Bowman, BA; Ford, ES; et al The continuing epidemics of obesity and diabetes in the United States Journal of the American Medical Association 28610:1195-1200, 2001 42 Medici, F; Hawa, M; Ianari, A et al Concordance rate for type II diabetes mellitus in monozygotic twins: Actuarial analysis Diabetologia 422:146-150, 1999 43 Poulsen, P; Kyvik, KO; Vaag, A; et al Heritability of type II non-insulin-dependent
diabetes mellitus and abnormal glucose toleranceA population-based twin study Diabetologia 422:139-145, 1999

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44 Herman, WH; Smith, PJ; Thompson, TJ; et al A new and simple questionnaire to identify people at increased risk for undiagnosed diabetes Diabetes Care 183:382-387, 1995 45 Griffin, SJ; Little, PS; Hales, CN; et al Diabetes risk score: Towards earlier detection of type 2 diabetes in general practice Diabetes/ Metabolism Research and Reviews 16:164-171, 2000 46 Adler, NE, and Ostrove, JM Socioeconomic status and health: What we know and what we dont Annals of the New York Academy of Science 896:315, 1999 47 Krieger, N; Williams, DR; and Moss, NE Measuring social class in US public health research: Concepts, methodologies, and guidelines Annual Review of Public Health 18:341-378, 1997 48 Beckles, GLA, and Thompson-Reid, PE Socioeconomic status of women with diabetesUnited States, 2000 Morbidity and Mortality Weekly Report 51:147-148, 159, 2002 49 CDC Behavioral Risk Factor Surveillance System, 2002 http://wwwcdcgov/brfss/June 2002 50 Harris, MI; Klein, R; Welborn, TA; et al Onset of NIDDM occurs at least 4-7 years before clinical diagnosis Diabetes Care 157:815-819,
1992 51 Harris, MI Undiagnosed NIDDM: Clinical and public health issues Diabetes Care 164:642-652, 1993 52 Harris, MI, and Eastman, RC Early detection of undiagnosed diabetes mellitus: A US perspective Diabetes and Metabolism Research Reviews 26:230236, 2001 53 Richards, GE; Cavallo A; Meyer, WJ III; et al Obesity, acanthosis nigricans, insulin resistance, and hyperandrogenemia: Pediatric perspective and

natural history Journal of Pediatrics 1076:893897, 1985 54 Longenecker, MP, and Daniels, JL Environmental contaminants as etiologic factors for diabetes Environmental Health Perspectives 109Suppl 6:871-876, 2001 55 Burg, JR, and Gist, GL The national exposure registry: Analyses of health outcomes from the benzene subregistry Toxicology and Industrial Health 143:367-387,1998 56 Institute of Medicine Committee to review the health effects in Vietnam veterans of exposure to herbicides Veterans and agent orange: Update 2000 Washington, DC: National Academy Press, 2001 57 Weiner, JP; Parente, ST; Garnick, DW; et al Variation in office-based quality A claims-based profile of care provided to Medicare patients with diabetes Journal of the American Medical Association 27319:1503-1508,
1995 58 Saaddine, JB; Engelgau, MM; Beckles, GL; et al A diabetes report card for the United States: Quality of care in the 1990s Annals of Internal Medicine 1368:565-574, 2002 59 Zoorob, RJ, and Mainous, AG III Practice patterns of rural family physicians based on the American Diabetes Association standards of care Journal of Community Health 213:175-182, 1996 60 Schoepflin, HM, and Thrailkill, KM Pediatric diabetes management in Appalachian Kentucky: Adherence of primary care physicians to ADA guidelines Journal of the Kentucky Medical Association 9710:473-481, 1999 61 Bell, RA; Camacho, F; Goonan, K; et al Quality of diabetes care among low-income patients in North Carolina American Journal of Preventive Medicine 212:124-131, 2001

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62 Rosenblatt, RA; Baldwin, L-M; Chan, L; et al Improving the quality of outpatient care for older patients with diabetes: Lessons from a comparison of rural and urban communities Journal of Family Practice 508:676-680, 2001 63 Saag, KG; Doebbeling, BN; Rohrer, JE; et al Variation in tertiary prevention and health service utilization among the elderly The role of urban-rural residence and supplemental insurance Medical
Care 367:965-976, 1998 64 Dansky, KH, and Dirani, R The use of health care services by people with diabetes in rural areas Journal of Rural Health 142:129-137, 1998 65 Witkin SR, and Klein R Ophthalmic care for persons with diabetes Journal of the American Medical Association 25119:2534-2537, 1984 66 Cheh, V, and Phillips, B Adequate access to posthospital home health services: Differences between urban and rural areas Journal of Rural Health 94:262-269, 1993 67 Diabetes Prevention Program Research Group DPPRG Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin New England Journal of Medicine 3466:393-403, 2002 68 Uusitupa, M; Louheranta, A; Lindström, J; et al The Finnish Diabetes Prevention Study British Journal of Nutrition 83Suppl 1:S137-S142, 2000 69 Tuomilehto, J; Lindström, J; Eriksson, JG; et al Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance New England Journal of Medicine 344:1343-1350, 2001 70 The Diabetes Control and Complications Trial Research Group DCCT The effect of intensive treatment of diabetes on the development and progression of long-term complications in
insulindependent diabetes mellitus New England Journal of Medicine 32914:977-986, 1993

71 UK Prospective Diabetes Study Group Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS 34 Lancet 352:854-865, 1998 72 UK Prospective Diabetes Study Group Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS 33 Lancet 352:837-853, 1998 73 Evans, GW, and Kantrowitz, E Strategies for reducing morbidity and mortality from diabetes through health-care system interventions and diabetes self-management education in community settings A report on recommendations of the Task Force on Community Preventive Services Morbidity and Mortality Weekly Report Recommendations and Reports 50:1-15, 2001 74 Brown, SA Studies of educational interventions and outcomes in diabetic adults: A meta-analysis revisited Patient Education and Counseling 163:189-215, 1990 75 Glasgow, RE; Hiss, RG; Anderson, RM; et al Report of the health care delivery work group Behavioral research related to the establishment of a chronic disease model for
diabetes care Diabetes Care 241:124-130, 2001 76 Institute of Medicine Committee on Quality of Health Care in America Crossing the quality chasm: A new health system for the 21st century Washington, DC: National Academy Press, 2001 77 Institute of Medicine Appendix D: Ambulatorycare-sensitive conditions and referral-sensitive surgeries Access to Health Care in America Washington, DC: National Academy Press, 1993, 219-222 78 CDC WISQARS leading causes of death reports, 1999-2000 2002 http://webappcdcgov/sasweb/ ncipc/ leadcaus10html2002

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Chapter Suggested Citation Dabney, B, and Gosschalk, A 2003 Diabetes in Rural America Rural Healthy People 2010: A companion document to Healthy People 2010 Volume 1 College Station, TX: The Texas AM University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center

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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://wwwlaurelhsorg;
http://wwwtiogapartnersorg

SNAPSHOT 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: monitors patient care and ensures continuous, consistent care for the diabetic patient; supports effective self-management through exams, referrals for eye and foot care, nutritional counseling, and documentation of self-management goal setting; and estimates the financial impacts of this intervention with another tool, known as IMPACT 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 THE
MODEL Blueprint: Beginning in January 2000, LHSs 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
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The collaborative supports a systematic approach to diabetes care and management

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 patients chart, and employed by the nurse or clinician with the patient in reviewing the patients condition and engaging the patient in continuing selfmanagement 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 LHSs 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 Hemoglobin A1c 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 HbA1c of 71 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 202/100,000 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 LHSs Laurel Health Center Diabetes Education and
Nutrition Counseling program was launched shortly after the

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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 US Health Resources and Services Administrations 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 LHS and TCPCH communicate to the community and the larger world through its regular newsletters and websites Staff of both organizations actively participate in state and national conferences in telling their story Many recent events
reflect the successes that these organizations have had in their disease management efforts In 1999, LHSs Diabetes Education and Nutrition Counseling program received the American Diabetes Associations Education Recognition Certificate for its diabetes self-management education program This recognition, successful work within the diabetes collaborative, and state support for expansion of the diabetes management work to other providers are among a string of successes for LHS and the larger TCPCH that have contributed to an award of a Community Access Program grant in 2001 to support development of a Community Health Plan, a jointly sponsored LHS-TCPCH managed care organization PROGRAM CONTACT INFORMATION 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

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Program Name: Delta Community Partners in Care Location: Clarksdale, Mississippi Problem Addressed: Diabetes/Hypertension Healthy People 2010 Objective: 5, 12 Web Address: None

SNAPSHOT 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 The regions economy is based primarily on agribusinesses associated with raising soybeans, cotton, and catfish This is a historically underserved area for health care, where 295 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 921 percent African American, 76 percent white, and 03 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 patients 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 THE MODEL Blueprint: DCPIC is a 501c3
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
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DCPIC attempts to reduce the barriers affecting its target population by providing outreach case management services

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 programs 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 101 visits to 065 from time of entry into the program to the time of the study The number of outpatient visits in the last year decreased from 068 to 031; and of the patients hospitalized in the past year, the number of nights stayed decreased as well from 637 nights to 340 The number of sick days in the past year also declined, dropping from 2674 days to 1577 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 64year-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
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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 WK 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 PROGRAM CONTACT INFORMATION Lela Keys Delta Community Partners in Care PO Box 1218 Clarksdale, MS 38614 Phone: 662 624-3484 Fax: 662 624-3203 E-mail: lbkeys2@bellsouthnet

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Program Name: Holy Cross Hospital Diabetes Self-Management Program Location: Taos, New Mexico Problem
Addressed: Diabetes Healthy People 2010 Objective: 5 Web Address: http://wwwtaoshospitalorg

SNAPSHOT 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 SelfManagement Program at Holy Cross Hospital can offer 100 percent access to quality diabetes education and support regardless of an individuals ability to pay THE MODEL 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 hospitals 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 663 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;
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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 diseasesuch 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 programs current goals include: Hemoglobin A1c 70 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 DSMPs 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 programs goal to provide 100 percent access to excellence in diabetes management and support will be reached by the following routes: Obtaining the American Diabetes Association ADA
Certificate of Recognition for the diabetes management program on June 7, 2001, allows the program to provide Medicare reimbursement and enables 40 percent of the population to access services without undue hardship

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With the ADA Certificate of Recognition and the move on December 5, 2000, to an independent location, HCH DSMP is well positioned to seek grants that will fund access to services for its underinsured patients Relocation to an independent site diminishes fragmentation of financial services Diabetes educators, prior to delivery of services, obtain registration and financial information as well as all insurance prior authorizations 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 directors 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 individuals 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 inkind 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
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HCH DSMP can offer 100 percent access to quality diabetes education and support regardless of an individuals ability to pay

micro albumin, and annual lipid profile As a participant in the NMMRA Diabetes Collaborative, HCH DSMP has a very strong quality improvement plan PROGRAM CONTACT INFORMATION Susan Kargula, RN, MSN, CDE Holy Cross Hospital Diabetes
Self-Management Program 1397A Weimer Rd Taos, NM 87571 Phone: 505 751-5750 E-mail: skargula@taoshospitalorg

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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

SNAPSHOT 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 THE MODEL Blueprint: WRRHCDC, a 501c3 non-profit organization, is part of the National Diabetes Collaborative NDC, which is comprised of FQHCs across the US 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

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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 an 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 90 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 eight sites in 2002 Beginnings: The Collaborative began in January 1998 and is comprised of FQHCs across the US The Arkansas DC originally consisted of two sites Challenges and Solutions: The strategic plan of WRRHC includes its commitment to the BHPCs 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 BPHCs Cardiovascular Collaborative in April 2001, which operates under the same principles

WRRHCDC
provides primary care and management of diabetes and associated conditions, regardless of the ability of the patient to pay

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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 BPHCs 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 latters 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 PROGRAM CONTACT INFORMATION 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@yahoocom

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