Advancing Diabetes Prevention and Quality Improvement in Rural Colorado
November is National Diabetes Awareness Month, an important opportunity for communities across the country to spotlight diabetes, a condition that affects millions, but can often be prevented or managed with awareness and action.
Early detection and proactive management are key to improving health outcomes, enhancing quality of life, as well as reducing healthcare costs. In CRHC’s Snapshot of Rural Health in Colorado, it was noted that in 2022, roughly 25% of all healthcare dollars were incurred by people with diabetes. Similarly, 1 in every 7 healthcare dollars were directly attributed to the disease. Uncontrolled diabetes can lead to serious complications, including kidney failure, blindness, and lower-limb amputations. Even among those who don’t have diabetes, highlighting the importance of healthier eating habits, physical activity, and weight management are important steps to help prevent new cases.
Primary care providers serve as the first line of defense in preventing and managing diabetes through evidence-based interventions. Proven methods such as lifestyle counseling, weight management programs, and regular A1 screening – are highly effective in delaying or preventing diabetes.
This month, as we observe National Diabetes Awareness, we are supporting these efforts by providing organizations enrolled in the Rural Connectivity Program (RCP) with meaningful tools to prevent, manage and improve outcomes for those at risk or already living with diabetes. Participants in RCP receive free access to the Community Analytics Platform’s Diabetes Screening and Diagnoses Report that contains valuable information about their facility’s unique patient population, allowing you to:
Identify At-Risk Patients
- Recent and historical A1C lab values indicate patients with Pre/Diabetes with no identified diagnosis
- Use data to ensure guideline-based screenings such as eye Exams and Kidney function tests are completed on schedule
Follow up on recent hospitalizations
- Organize care coordination efforts to monitor ADT messages
- Assess recurrent hospitalizations trends amongst those at risk or with diabetes
Continue Quality Improvement Efforts
- Set measurable goals, such as increasing A1C screening rates or reducing diabetes related readmissions
- Enhance Preventative Care Workflows
Address Social Determinants of Health (SDOH)
- Review demographic language data to tailor communication and outreach materials to different populations
For patients with established diabetes, effective chronic disease management is essential. Integrating and sustaining a Chronic Care Management (CCM) Program can provide consistent, patient-centered support while easing the coordination burden on clinical teams.
CRHC is leading a Chronic Care Management (CCM) Sustainability Program– a sustainability initiative designed to help you optimize your CCM program, improve patient outcomes, and ensure long-term success. For more information or to sign up, please contact Jennifer at: jgrant@coruralhealth.org
Want to use data to improve outcomes in your community?
We can help! Your participation in the Rural Connectivity Program allows you access to CRHC’s team of Quality Improvement Specialists, who are available to support your team in improving your community’s healthcare outcomes. Our RCP team provides technical assistance tailored to your clinic’s specific goals. We’re here every step of the way to make sure you get the most out of this platform for your organization.
For more information about the reports available in the CAP, contact the Rural Connectivity Team at ruralconnect@coruralhealth.org.
Food Resources
Food insecurity – the lack of consistent access to enough food for an active, and healthy life; is a potent risk factor for the development and progression of diabetes. Access to food pantries plays a vital role in supporting those individuals at risk. Consuming a diet rich in vegetables, fruits, whole grains and lean proteins is one of the ways that those at risk of developing diabetes, or those living with diabetes can prevent and manage their condition. Below you will find resources on available food banks in the state of Colorado:
- FindHelp.org– find food banks and resources based off zip code
- MyFriendBen.org – helps you screen for benefits you are likely eligible for
- Food Resource Finder | United Way 211– find food banks and resources based off zip code
- Find Food | Food Bank of the Rockies – serves 32 counties. If your county is not in our service area, please call the Food Resource Hotline at 855-855-4626 to find a food pantry or distribution near you.
- Project Angel Heart – prepare and deliver medically tailored meals to people living with severe illness
Diabetes Management Resources:
- National Diabetes Prevention Program
- Four steps to manage diabetes – CDC (multiple languages)
- American Diabetes Association (ADA) – Patient education Library
- Association of Diabetes Care & Education Specialists – Tools and Resources
Diabetes Friendly Recipes & Diet Management:
