“Anyone Can Manage Diabetes”: A Public Health Department Approach

Objective:  To describe a public health department approach to implementing a diabetes self-management program for the uninsured and underinsured population with Type 2 diabetes in a rural Missouri Community.

Methods:  The Pike County Health Department organized a collaborative team comprised of a physician, nurse practitioner, care coordinator, educator, dietitian, fitness trainer and social worker to provide the best possible support for patients with diabetes. Uninsured/underinsured patients can see a provider and other members of the care team at no cost. For each patient, the care team guides development of a diabetes self-management plan, self-management education and goal setting.  Unique aspects of this program include availability of a social worker on the team to address the unmet social and emotional needs and the role of patients from the Pike County Diabetes Coalition in helping to shape intervention strategies. Clinical and behavioral data are being used to assess this approach.

Results:  Not only are clinical measures (A1c, LDL, and BP) somewhat improved, but the percent of patients who now receive ADA recommended clinical procedures (e.g., regular A1c, foot and eye exams) has clearly improved. Increases in collaborative goal setting have been documented as have improvements in eating behaviors and taking medications as prescribed.

Conclusion:  This collaborative effort for diabetes self-management shows promise for achieving improved health status for diabetic residents of Pike County. Using the data for quality improvement has allowed the team to identify problems as well as make and test improvement plans to better meets the needs of patients.