Rural Health Network Development Program (RHND) – Mississippi Diabetes Network

The Georgia Heath Policy Center recently spoke to Catherine Moring, Ph.D., project director for the Mississippi Diabetes Network about how formalizing network partnerships is enabling rapid expansion of resources and services for people living with diabetes and for health care providers treating those with diabetes in Mississippi.

 

To date, what has been the biggest accomplishment or win for your network development?

Bringing together a group of organizations that represent both traditional health care as well as nontraditional health care partners has been a great accomplishment. It has been very neat to see our partners come together and unite to work together to address one of the biggest threats to our state and health care landscape — the extreme diabetes epidemic that plagues our state. Some of our partners have been working together for a decade, but with this grant we have been able to formalize the relationships and grow and sustain our efforts to address and combat diabetes on a unified front. An early accomplishment of the network’s collaboration is the growth and impact of its Diabetes Solutions service, which is a virtual diabetes coaching program housed out of Tallahatchie General Hospital Medical Foundation’s James C. Kennedy Wellness Center. Through network collaboration and our referral network, we are now reaching more patients and serving a broader geographical area. Patients who participate in Diabetes Solutions services achieve clinically meaningful and statistically significant reductions in A1C and weight, as well as improvement in 30 other symptoms that are measured every six months.

 

What is a learning that you would share with an organization launching a similar network?

It is an accomplishment to bring partners — big and small — together, but it can be challenging to keep everyone engaged. I think what has helped us most is being honest and transparent when challenges come up. When hiccups come up, we talk about it, and we work through those problems together. Frequent communication, but not over communication, is essential.

Another big piece is trying to see who is already part of the network that can offer value, and then where are the gaps, where you need to either hire people or change roles. I read a book years ago and it talked about that when you are building something, you have to have the right people on the bus and in the right seats. It is important to figure out what role everybody can play. Similarly, you have to make sure that you bring partners in who share your vision and mission and are passionate about what it is that you are doing. You need to be able to tell them what is in it for them, what value will this add, and why they should want to be a part of it.

On the flip side, not everybody needs to be a member of your network and not everybody is a good fit. Similarly, not every funding opportunity is a good fit. It is about getting clear on what it is that you want to do and how you want to get there. It is this idea of being an inch wide and a mile deep versus a mile wide and an inch deep. Being really clear about what you do, how you do it, and who you do it for is really helpful.

 

How do you see participation in the Federal Office of Rural Health Policy’s grant program impacting your broader health improvement efforts?

As health care providers, we make a lot of assumptions that our patients are noncompliant or they just do not care, but really, they often just don’t know what they don’t know. Providing that line of education and offering the supports can be meaningful. Our vision is for every health care provider in Mississippi to know about the network and know that there are resources for their patients that have diabetes and that there are different options of resources for those patients. This grant is giving us the opportunity to build out our resources even more.

 

Do you have an example or story that illustrates the value of planning for a rural health network instead of a single organization at the helm?

We had a referral this morning for a patient with A1C of 13.6, which is extremely high. He had been discharged from the emergency department to his primary care and only given a prescription for low-dose metformin. He was not given other medications to bring his blood sugars down or taught how and when to check his blood sugar. Thankfully, though, this patient was referred to Diabetes Solutions. So, the network can step in and get this patient better taken care of with education, nutrition counseling, and teaching them about diabetes; how to check their blood sugar; and the other self-care behaviors important for diabetes management.

There is real strength when you can come together and add value to each other. That is our big pitch when we are recruiting new providers to refer to Diabetes Solutions — we are not competition to your care, but a complement to your care. Patients are still going to come see their provider every three to six months for follow-up care, but this is an adjunct, an add-on, where we can help you help patients navigate diabetes more efficiently. Most clinics, especially in rural Mississippi, do not have the bandwidth to have dieticians or certified diabetes educators on staff. We have those resources. Most importantly, patient care is improved, and we achieve more positive health outcomes working together than we would alone.

 

What is next on the horizon for your grant-funded program?

We had 225 new people enroll in Diabetes Solutions last year. We want to continue to grow those referrals but there are hundreds of thousands of people in Mississippi with diabetes and we can only reach so many with one-on-one coaching. We are looking for ways we can reach the masses. We are going to expand online resources with online courses for patients with diabetes, as well as public topics on managing diabetes, preventing diabetes, or keys to weight management and sustainable weight loss. We would also like to have courses for continuing medical education for health care providers specific to the treatment of diabetes.

We also want to improve screening and diagnostics. We would like help raise awareness and help to identify diabetes earlier in the disease process through screenings at worksite and community settings, and then providing follow-up care — getting those identified with diabetes or prediabetes to primary care and providing resources and services for folks that have pre-diabetes, diabetes, or hypertension to make sure that they don’t end up with uncontrolled diabetes, complications related to diabetes, or in the emergency room.

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