Redesigning Diabetes Care in Rural Fee-for-Service Practices

Intervention title:
Redesigning Diabetes Care in Rural Fee-for-Service Practices—East Carolina Health–Bertie All-County Health Services (formerly East Carolina Health-University Health System); Windsor, N.C.

Improve diabetes care for rural African American patients.

Researchers with Vidant Health and East Carolina University Department of Family Medicine used a “circuit-rider” approach to send nurse, pharmacist, and dietitian certified diabetes educators (CDEs) to rural clinics to become part of primary care office visits for African Americans with type 2 diabetes. The CDEs partnered with physicians to coach patients in self-management. Patients with diabetes were scheduled for provider visits and education visits on the same day. Researchers believe that this methodology could be uniquely suited for medically underserved communities, allowing multiple practices to share the cost of utilizing a skilled diabetes clinician.

The researchers conducted a randomized trial that enrolled 368 African American patients with diabetes at rural clinics using CDEs, and 359 patients at clinics not using this approach (727 patients total). The intervention had a significant effect on HbA1c and lipid levels, but not blood pressure, at follow-up (mean time: 3.3 years). Because visit frequency was similar in intervention and control practices, the improvement in clinical outcomes appeared to be related to improvements in the intensity and quality of the visit in the intervention practices.

Vidant Family Medicine–Windsor (formerly East Carolina Health-University Health System)
P.O. Box 40, 1403 South King Street
Windsor, NC 27983

“We found that the diabetes educator-coach enabled the clinics to be much more aggressive in treating to target. Instead of having patients with an abnormal A1c or lipid or blood pressure level come back in three months, the educator-coach would bring them back in 10 days and meet with them first, even before they saw the physician. The educator could then ask questions a physician might not have time to ask—for example, ‘show me how you take your medicine,’ or, ‘take me through your diet over the past few days.’ This was critical in figuring out whether medication needed to be adjusted or something else was going on, and then that information could be discussed when the physician was present.”

Paul Bray, MA, LMFT
Vidant Medical Group, East Carolina University Project Coordinator-ECARE
Principal Investigator

Intervention: One family practice clinic at Bertie Hospital and two practices within the Roanoke Chowan Community Health Center. Control: Five community health centers in rural eastern North Carolina.

Clinical areas affected:

  • Primary care

Staff involved:

  • Administrator, Clinical Integration Quality, Vidant Medical Group
  • Executive Director, Roanoke Chowan Community Health Center
  • Project Coordinator
  • Certified Diabetes Educator (part-time)
  • Registered Nurse-CDE
  • Registered Dietician-CDE
  • PharmD-CDE (part-time)

Initial piloting of the model through final data collection took place between 2002 and 2010. The RWJF grant period for conducting the randomized trial was May 2008 through April 2010.

Paul Bray, MA, LMFT
Principal Investigator
P: (252) 717-4402

Advice and lessons learned:

  1. Measure outcomes and share them with physicians regularly. An integrated model of diabetes care depends on having a fully functional electronic medical record with the capacity to report key diabetes indicators, as these are the fuel that drives improved clinical outcomes. The data should be shared with physicians at monthly meetings. Getting physicians engaged is critical in sustaining a new care-delivery process.
  2. When integrating an educator-coach into an ambulatory team, start slowly, give it time, and treat it as a paradigm shift rather than an add-on. A pilot period with one educator-coach at one site can be very helpful in demonstrating the value of this approach to ambulatory care teams. Encourage both formal team meetings and less formal hallway consultations for sharing information about the care of patients with diabetes.
  3. Link with a local academic research institution for partnership and outcome analysis. Besides the valuable data provided, such partnerships add credibility and support funding sustainability.
  4. Publicize positive results. Articles in health system publications and local newspapers can be a powerful tool for getting buy-in from health system leaders.

Cost estimate:
Although the project did not perform a cost-benefit analysis, it did calculate the cost of the intervention to be $91,800 for one full-time educator-coach in year one and $86,800 in subsequent years. One full-time educator-coach usually serves three clinics per week and covers a diabetes panel of 800 patients. The researchers concluded that the costs should be sustainable in a reformed health care environment that ties payment more closely to outcomes.