1096-P: The Diabetes On Track Model—Creating a Framework for Improving Diabetes in Rural Nebraska

Introduction & Objective: Outcomes for people with diabetes in rural areas are worsening, widening disparities between urban and rural populations. The objectives of Diabetes on Track are to improve outcomes for people at risk for or living with pre-diabetes and type 2 diabetes in rural Nebraska.

Methods: Investigators engaged health departments and primary care clinics in two rural communities. Community coalitions were developed with a focus on improving screening rates. Clinical interventions include a Project ECHO curriculum to disseminate evidence-based education via case-based learning, funding of RN health coach positions, and support for clinical pharmacy time. Individual provider dashboards were developed, along with a value-based incentive program tied to diabetes-related quality metrics (A1c monitoring and control; screening for dyslipidemia, nephropathy, and retinopathy). A patient pathway team aims to increase clinician awareness of community resources and improve referral workflows.

Results: Project ECHO sessions have been regularly attended with good participation. Clinics are increasing use of team-based care for people with diabetes. Over 8 months, the enhanced team approach generated 18 referrals to pharmacy, 89 to Diabetes Education, and 134 to Health Coaching. A prediabetes registry was created and thus far, 225 patients have been contacted about their risk. All diabetes-related quality metrics have improved, primarily at the site where clinicians were given visibility to the incentive program. One location has joined an ACO.

Conclusion: Improving diabetes at a community level requires a multi-pronged approach. Our model utilizes community interventions, healthcare team interventions, and a patient pathway to improve communication between health departments and local clinics. Understanding local relationships and developing trust takes time but is vital. The most impactful intervention to date has been the value-based incentive program.