EXECUTIVE SUMMARY
Rural Health Network Development Grant
Executive Summary
The Tallahatchie General Hospital Medical Foundation was awarded the Rural Health Network Development Grant from the Health Resource and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP) to spearhead the implementation and expansion of the Mississippi Diabetes Network, referred hereafter as the Network. It is a funding opportunity designed to develop a sustainable network to address gaps and needs in rural healthcare. The key purpose of the Network is to address the massive burden diabetes places on our state, the healthcare system, and residents (and their families) living and suffering with diabetes and its related comorbidities. As such, the Network is committed to excellence in diabetes care, management, and prevention strategies. The Network aims to be a premier resource statewide for patients living with diabetes, health care providers treating those with diabetes, and the general public looking to improve health and quality of life.
Key Deliverables
Provide resources and services for people with and at risk for developing diabetes and increase access to Diabetes Self-management Education Services (DSMT/DSMES), Medical Nutrition Therapy (MNT), patient education, and coaching services (diabetes solutions).
Provide increased access to quality, valuable, and accessible Continuing Medical Education (CME) and training opportunities to health care providers at all levels focused on insulin resistance, diabetes, and other related conditions to support their ability to effectively prevent and manage diabetes in a high-risk, medically complex patient population.
Conduct onsite worksite and community screening events to improve screening and diagnostics, detect diabetes earlier in the disease process, and provide follow-up clinical care and diabetes services to those who have or at risk for developing diabetes.
Connect patients to behavioral health care and increase access to such services for patients with emotional health concerns.
Positively influence policy and reimbursement for DSMT/DSMES/MNT, especially in rural areas.
The Network’s overarching aim is to improve access to and quality of diabetes care through sustainable health care programs and services created as a result of the Network’s collaboration. Associated aims are to demonstrate improved health outcomes and community impact, promote the sustainability of the Network through the creation of diverse products and services, and utilize evidence-based and promising practice models in the delivery of health care services.
The primary goals of the Network are to 1) Implement novel and promising strategies designed to improve diabetes care and management at both the patient and provider level; 2) Improve health outcomes and quality of life in those with and those who are at risk for developing diabetes; 3) Reduce healthcare costs associated with the treatment of diabetes and its related comorbidities; and 4) Reduce the incidence and prevalence of diabetes in our service area.
Using a systems of care approach, the Network will 1) Implement and utilize evidenced-based and promising strategies designed to improve diabetes prevention, treatment and management at both the patient and provider level; 2) Provide ample training to health care providers specific to diabetes to assure providers are well-versed in the most up-to-date research and treatment modalities including pharmaceutical, lifestyle, and nutrition tactics; 3) Expand the Diabetes Solutions coaching services referral network to include clinics and health care providers throughout the service area; 4) Increase screening rates in the worksite and community settings to detect undiagnosed prediabetes and diabetes and provide appropriate follow-up care and resources; and 5) Increase access to clinical care for diabetes treatment as well as behavioral health care through the provision of telehealth and coaching services.
Broadly, the Network expects to improve health outcomes and health status in those with diabetes, including prediabetes, reduce unnecessary healthcare costs, reduce hospital readmissions and emergency department visits associated with diabetes and its related comorbidities, and ultimately reduce the incidence and prevalence of prediabetes, diabetes, and uncontrolled diabetes in our service area.
Founding Network Members include: Tallahatchie General Hospital Medical Foundation | Tallahatchie General Hospital | University of Mississippi’s Community First Research Center for Wellbeing and Creative Achievement | William Carey University College of Osteopathic Medicine | The National Diabetes and Obesity Research Institute | Baptist Memorial Hospital – North Mississippi.
Network Aims
Provide training opportunities specific to the management and treatment of diabetes and insulin resistance to healthcare providers, both in person and virtually through the provision and creation of virtual courses and in-person events.
Provide a menu of resources and an array of services to those with prediabetes and diabetes in order to improve their health and assist with disease management and prevention.
Create partnerships with large worksites and community organizations to provide health fairs and screening events to detect undiagnosed diabetes within the network’s service area.
Expand Diabetes Solutions reach and referral network to impact more patients throughout the service area. The Diabetes Solutions model achieves an average 2.7 point reduction in A1c and a 4.0 point reduction in patients who enroll with an A1c above 9.0%. Over half of participants reach their target A1c goal within 3 to 6 months. We also see symptom improvement across the board in other areas of concern.
Increase access to diabetes care and coaching using telehealth and virtual coaching programs.
Increase access to behavioral health care via telehealth and connect patients who are experiencing behavioral health concerns to behavioral health specialists.
Control and reduce health care costs associated with diabetes care including a reduction in hospital readmissions by working with patients upon discharge with a diagnosis of diabetes.
Thoroughly evaluate the Network’s activities and outcomes and disseminate findings.
Increase reimbursement rates and opportunities for reimbursement for DSMT programs and MNT by showing the ROI on the benefits of coaching services.
We are a united force against diabetes.
