Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes. Journal of general internal medicine BACKGROUND:Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging. OBJECTIVE:To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas. DESIGN:Mixed-methods implementation study. PARTICIPANTS:230 patients with clinic-refractory, uncontrolled T2D. INTERVENTION:ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period. MAIN MEASURES:Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c). KEY RESULTS:From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (- 1.43%, 95% CI: - 1.64, - 1.21; P < .001). Benefits persisted at 12 (- 1.26%, 95% CI: - 1.48, - 1.05; P < .001) and 18 months (- 1.08%, 95% CI - 1.35, - 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years. CONCLUSIONS:When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population. 10.1007/s11606-021-07281-8

The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia. Smalls Brittany L,Adegboyega Adebola,Combs Ellen,Rutledge Matthew,Westgate Philip M,Azam Md Tofial,De La Barra Felipe,Williams Lovoria B,Schoenberg Nancy E BMC public health BACKGROUND:The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community. METHODS:Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively. RESULTS:The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care. CONCLUSIONS:This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population. TRIAL REGISTRATION:US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov . 10.1186/s12889-021-11777-7

Self-management of diabetes and associated comorbidities in rural and remote communities: a scoping review. Rasmussen Bodil,Wynter Karen,Rawson Helen A,Skouteris Helen,Ivory Nicola,Brumby Susan A Australian journal of primary health Chronic health conditions are more prevalent in rural and remote areas than in metropolitan areas; living in rural and remote areas may present particular barriers to the self-management of chronic conditions like diabetes and comorbidities. The aims of this review were to: (1) synthesise evidence examining the self-management of diabetes and comorbidities among adults living in rural and remote communities; and (2) describe barriers and enablers underpinning self-management reported in studies that met our inclusion criteria. A systematic search of English language papers was undertaken in PsycINFO, Medline Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, EMBASE and the Cochrane Database of Systematic Reviews, searching for literature indexed from the beginning of the database until 6 March 2020. Essential key concepts were diabetes, comorbidities, self-management and rural or remote. Twelve studies met the inclusion criteria. Six of these reported interventions to promote self-management for adults with diabetes in rural and remote communities and described comorbidities. These interventions had mixed results; only three demonstrated improvements in clinical outcomes or health behaviours. All three of these interventions specifically targeted adults living with diabetes and comorbidities in rural and remote areas; two used the same telehealth approach. Barriers to self-management included costs, transport problems and limited health service access. Interventions should take account of the specific challenges of managing both diabetes and comorbidities; telehealth may address some of the barriers associated with living in rural and remote areas. 10.1071/PY20110

Effectiveness of diabetes education interventions in rural America: a systematic review. Health education research The purpose of this systematic review is to summarize the characteristics of recent studies on diabetes education interventions in rural areas and identify the relative proportion of studies with characteristics of interest that showed a reduction in glycated hemoglobin (A1C). A systematic literature search was performed in Web of Science, PubMed and PsychInfo, using keywords and Medical Subject Heading terms. Articles conducted in rural areas of the United States tested an educational intervention for people with type 2 diabetes, and reported outcomes were identified. A total of 2762 articles were identified, of which 27 were included. Of the 27 articles, most were implemented in the Southeast (n = 13). Of the 21 interventions that measured A1C, 10 reported a statistically significant decrease in A1C. The proportion of studies with a significant A1C reduction was higher for the studies that used telehealth/online, delivered by a collaboration between health-care professionals and lay educators or included family or group components. Only three studies included their criteria in determining rurality. Future diabetes education interventions may consider including family members or group sessions, holding online sessions and partnering with local resources. Additionally, stronger research methods are needed to test practical and effective interventions to improve diabetes education in rural areas. 10.1093/her/cyac039

Improving diabetes care of community-dwelling underserved older adults. Journal of the American Association of Nurse Practitioners BACKGROUND:Diabetes care among rural underserved older adults is negatively affected by social determinants of health (SDOH). Although there is an increased awareness of this problem, evidence-based clinical and community interventions are not widely integrated. This project implemented telemedicine and community health worker (CHW) interventions to improve diabetes management and outcomes. LOCAL PROBLEM:One in five older adults with diabetes mellitus (DM) at a Federally Qualified Health Center in southwest Ohio has uncontrolled disease, largely due to their limited resources and ability to participate in routine clinical management. METHODS:This quality improvement project used a pre-post intervention design. Participants were adults aged ≥65 years with uncontrolled DM type 1 or 2. The outcomes of interest included A1C values, diabetes self-care activities, diabetes knowledge, and patient and health care provider (HCP) satisfaction levels. INTERVENTIONS:The project involved biweekly CHW home visits and diabetes self-management education for 12 weeks. The CHWs, with supervision from a nurse practitioner, conducted SDOH assessments and basic education, and facilitated same-day telemedicine appointments with the HCP to reinforce disease management. RESULTS:The A1C levels and diabetes knowledge of older adults significantly improved after three months. However, there were no statistically significant changes in diabetes self-care activities. The patients and HCPs were highly satisfied with the project interventions. CONCLUSIONS:This project delivered patient-centered and equitable diabetes care services that were previously unavailable to underserved older patients, while demonstrably improving outcomes. Future research should evaluate the cost-effectiveness, long-term impact, and sustainability of the project in other primary care settings. 10.1097/JXX.0000000000000773