Background: In rural areas, lack of access to specialty care and intensive self-management programs may perpetuate poor diabetes outcomes. Telehealth presents an opportunity to extend specialized diabetes care to rural areas, but may be difficult to implement in routine practice. We examined rural implementation of an intensive telehealth intervention designed to leverage existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure for patients with uncontrolled type 2 diabetes despite receiving routine care.

Methods: Advanced Comprehensive Diabetes Care (ACDC) is a 6-month telehealth intervention for patients with poor glycemic control (varies by site, typically ≥8.5%), established as effective in a prior randomized trial. ACDC combines telemonitoring, self-management support, and clinician-guided medication management, and is delivered by clinical HT nurses using standard HT equipment. During 2017-2019, we implemented and evaluated ACDC at 5 rural VHA sites with guidance from the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Results: From 2017-2019, 30-100% of eligible patients at each site were enrolled in ACDC, for a total of 125 patients (94% male, 89% white, 71% classified as rural/highly rural). Across sites, mean HbA1c improved from 9.25% at baseline to 7.89% at 6 months (-1.36%, 95% CI: -1.61,-1.11; p<0.001), a benefit that persisted at 12 (-1.22%, 95% CI: -1.48,-0.97; p<0.001) and 18 months (-1.07%, 95% CI -1.40,-0.73; p<0.001). Implementation at each site was acceptable, with an average of 8-10 of 12 scheduled ACDC calls completed. Qualitatively, ACDC enhanced patient engagement and awareness of glycemic control, while moderately increasing workload for providers.

Conclusions: When strategically designed to use existing infrastructure, intensive telehealth interventions are conducive to implementation and produce sustained improvements in glycemic control among rural patients.


E.A. Kobe: None. A. Lewinski: None. S. Danus: None. E.L. Sidoli: None. B. Greck: None. L.C. Horne: None. D. Saxon: None. S.D. Shook: None. L.E. Aguirre: None. C. Evenson: None. C.S. Elizagaray: None. G.L. Jackson: None. H.B. Bosworth: Board Member; Self; Preventric Diagnostic. Consultant; Self; Abbott, Medicines Company, Novartis Pharmaceuticals Corporation. Research Support; Self; improved patient outcomes, Novo Nordisk Foundation, Otsuka Pharmaceutical Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Pharma foundation, Proteus Digital Health, Proteus Digital Health, Sanofi. D. Edelman: None. M. Crowley: None.


VA Office of Rural Health; Veterans Rural Health Resource Center-Iowa City (13366); National Center for Advancing Translation Sciences (TL1TR002555); VA Health Services Research and Development Service (IIR 16-213, 08-027); U.S. Department of Veterans Affairs (TPH 21-000); Durham Center of Innovation to Accelerate Discovery and Practice Transformation (CIN 13-410)

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