Northeast Missouri Rural Health Network

CareLink Regional Services for Better Self-Management of Diabetes Program

117 W. Potter Avenue
Kirksville, MO 63501
Phone: (660) 665-0330
Toll Free: (877) 539-2227
Fax: (660) 665-0030

nmrhn@sbcglobal.net

www.nmrhn.org

The CareLink Regional Services for Better Self-Management of Diabetes Program
 is a collaborative project between multiple member agencies of the Northeast Missouri Rural Health Network to develop a coordinated system of care for uninsured, underinsured, and underserved type 2 diabetes patients in an eleven-county area.

The program facilitates a means for early intervention, provides training for development of self-management skills and care coordination services, and links patients with other resources as needed.  Within this region, all the counties have median household incomes far below the state average and 17 percent of the population reports income below the federal poverty level. It is estimated that 18.4 percent of this region is uninsured and while others may have health insurance coverage, they may not have benefits for diabetes education and support.  Through educational sessions and dedicated follow-up, the CareLink Regional Services for Better Self-Management of Diabetes Program provides patients with the tools and support necessary to successfully manage their diabetes, improve their health, and their quality of life.

The Northeast Missouri Rural Health Network (NMRHN) was created to achieve regional health improvements through collaboration, coordination, and sharing of services and resources among its member agencies, which include health departments, hospitals, federally qualified health centers, an independent physicians association, ambulance districts, mental health providers, and nursing homes.  For more information on the Network, its member agencies and other patient-based programs, please visit their website at www.nmrhn.org.   

Program Logic Model (download here)

 

Key Intervention Strategies:

  • Implementation of the ADA seven-question risk assessment tool as part of routine visit questionnaire at health departments and clinics
  • Assessment appointments during which plans of care and initial goals are established
  • Patient encounter forms and care coordination documentation shared among providers and care team to track progress and assess needs
  • Option of self-management group training sessions or one-on-one education for those not comfortable in group setting or have special learning needs
  • Use of handouts designed for patients with low-literacy skills
  • Routine follow-up contacts by patient navigators and care coordinator
  • Implementation of provider diabetes flow sheet redesigned to encourage utilization of the ADA Clinical Practice Standards
  • Transportation and prescription medication assistance services
  • Assessments and self-management training conducted via telehealth when needed
  • Community self-management classes

Key Accomplishments:

  • Partner clinics and health departments trained
  • Continuous offerings of self-management classes throughout service region
  • Responded to unmet need to reach uninsured, at risk women with gestational diabetes  
  • Implemented a patient navigator program  
  • Number of patients with A1c level less than 7 has increased 
  • Improved clinical procedures outcome measures
  • Improved patient achievement in setting self-management goals
  • Improvements made in following food plans
  • Increased total number of minutes spent in physical activity
  • Program services extended to reach high risk patients with pre-diabetic conditions
  • Provided care coordination for all patients completing self-management training
  • Improved referral and monitoring processes

Key Materials and Presentations: