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DOI: 10.1177/0145721706296029 © 2006 American Association of Diabetes Educators; Published by SAGE Publications
Improving Access to Quality Diabetes Education in a Rural StateThe Montana Quality Diabetes Education InitiativeFrom the Montana Department of Public Health and Human Services, Helena (Ms Butcher, Ms McDowall, Ms Oser, Ms Johnson, Mr Harwell, Dr Helgerson, Dr Gohdes); St Patrick Hospital and Health Sciences Center, Missoula, Montana (Ms Gilman); St Vincent Healthcare, Billings, Montana (Ms Meszaros); Great Falls Clinic, Great Falls, Montana (Ms Bjorsness); and Fort Peck Service Unit, Indian Health Service, Poplar, Montana (Ms Madison). Correspondence to Marcene K. Butcher, RD, CDE, Montana Department of Public Health and Human Services, Cogswell Building, C-317, PO Box 202951, Helena, MT 59620-2951 (marcibutcher{at}msn.com).
Purpose Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities. Methods To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service. Results From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increasedfrom 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties. Conclusions Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.
Diabetes self-management education (DSME) is an integral and fundamental component of quality diabetes care, but access to diabetes education, particularly in rural states, has been very limited.1,2 Most persons with diabetes in Montana receive their medical care in the primary care setting, where formal DSME programs and certified diabetes educators (CDE) are not uniformly available in small rural towns. A study conducted in 1999 and 2000 in Montana's largest city found that on average, the outlying communities served by that city's health care systems were 182 miles from the closest urban area with a CDE.3 The infrastructure, resources, and institutional support to develop American Diabetes Association (ADA)–recognized education programs in rural primary care facilities is often limited. In addition, health care professionals who provide care for patients with diabetes in rural settings often have limited experience and training in diabetes education concepts and may lack the skills to provide comprehensive self-management education. Finally, the amount of Medicare reimbursement for education and the costs to develop and maintain a recognized program are problematic for both urban and rural settings.2,4,5 This article describes the process and the results of a unique statewide mentoring and technical assistance program, the Montana Quality Diabetes Education Initiative (QDEI), developed by the Montana Diabetes Control Program (DCP) in cooperation with the Montana American Association of Diabetes Educators (MAADE). Initially, the efforts were targeted to increase personnel skills in providing quality diabetes education across the state. As the initial efforts developed, the program then adapted to address sustainability by assisting educators in attaining and maintaining recognized diabetes education programs through the ADA or the Indian Health Service (IHS).6
Setting Montana is geographically large but has a relatively small population. In 2000, the total population of Montana was 902 195 spread across 147 042 square miles, a population density of 6.2 persons per square mile.7 Of the 56 counties in Montana, 48 were defined as frontier (nonmetropolitan counties without a city of 10 000).8 The remaining 8 counties were small metropolitan counties (n = 2) or nonmetropolitan counties with a city of 10 000 or greater (n = 6). These 8 counties were defined as urban counties. In 2000, most residents were white (91%) or American Indian (6%).7
Developing and Implementing the Mentoring Program A part-time registered dietitian and CDE at the Montana DCP coordinated the program. The coordinator assessed the learning needs of each health care professional enrolling in the program, outlined a course of self-study and reference materials, and matched the participant to a volunteer CDE mentor. Participants could choose an initial training level from basic to advanced and could elect to progress to a higher level. Mentors guided and assisted the participants through on-site visits (when available), telephone conferences, and e-mail contacts. Participants were also encouraged to observe diabetes education in action, performed by their mentors or on site at another structured diabetes education program. Because of the long geographic distances in Montana, travel costs, and the burden of time away from work for both the participants and volunteer mentors, the program was designed to be self-study; most of the mentoring was conducted by telephone and e-mail. There were no direct costs for health care professionals who participated. QDEI established a lending library and provided reference materials to participants when they enrolled. Examples of these materials include A Core Curriculum for Diabetes Education from the AADE, Understanding Diabetes by H. Peter Chase (Barbara Davis Center for Childhood Diabetes), the American Diabetes Association Complete Guide to Diabetes from the ADA, and the current Clinical Practice Guidelines from ADA. Volunteer CDE mentors were recruited with assistance from the MAADE. Currently, QDEI has 16 volunteer mentors. A mentoring partnership manual was provided to both the mentors and the participants to guide them through the process. The mentor and participant partnerships were individualized to meet the needs of both individuals, and the program coordinator provided ongoing assistance through the mentorship.
Technical Assistance for Diabetes Education Program Recognition
Program Evaluation
From 2000 to 2005, 90 health care professionals enrolled in QDEI, most of whom were nurses (76%) or dietitians (21%). Thirty-nine participants enrolled in the basic level, 12 in the intermediate level, and 44 in the advanced level. Over the 6-year period, the mean number of health care professionals participating annually was 37. Twenty-seven of the 90 enrollees (30%) completed their mentoring option: 14 in the basic level, 2 in the intermediate level, and 16 in the advanced level. Five participants completed more than 1 level. Most of the health care professionals completing the program provided services in frontier counties (66%). Thirteen of the 27 participants (48%) completing the advanced level achieved the CDE certification. Overall, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. The number of frontier counties with 1 or more CDEs increased from 18 in 2000 to 28 in 2005 (Table 1).
Twenty-three of the 27 participants (85%) who completed the mentoring program returned the evaluation. Satisfaction was high; 91% of participants indicated that their mentor was very helpful, 96% indicated that the learning materials were very helpful, and 96% indicated they accomplished their goals. Over the 6-year period, QDEI provided technical assistance for diabetes education program recognition to 30 facilities, 25 of which achieved recognition for outpatient education. Technical assistance topic areas most frequently covered were choosing curriculum, policy and procedure development, continuous quality improvement, application and programmatic assistance, options for continuing education for non-CDE instructors, and the development of networks with other educators across the state. Overall, the number of recognized education programs increased 10-fold from 2 in 2000 to 22 in 2005. Twelve (55%) of these newly recognized programs were located in frontier counties (Table 1). During this 6-year time period, 4 facilities could not maintain their recognition, primarily because of the loss of the primary educator or the program manager.
The Montana QDEI is a cooperative mentoring program that has been successful in increasing access to quality diabetes education across a large rural state. The number of health care professionals trained in the basics of diabetes education and the number of CDEs in the state has increased, particularly in frontier counties. In addition, technical assistance for ADA and IHS diabetes education program recognition has supported the growth of recognized programs across the state. This process grew from the observation that it was a significant challenge for facilities to both implement new education programs and sustain existing education programs, particularly in Montana's small rural communities. Strengths of this program are the collaborative approach and the relative low cost to provide support to health care professionals. The Montana DCP recruited volunteer educators to act as mentors, and they provided invaluable time and support to participants and the program. In turn, a strong network of educators developed across the state who shared their knowledge, experience, education materials, curricula, and protocols. The overall cost of this program included only the part-time coordinator's salary, staff support from the Montana DCP, and the cost for resource materials for the lending library. But face-to-face contact was minimal because of the distances. Mentors and participants often communicated only through telephone and e-mail. Several challenges for diabetes education in rural areas were encountered, which have been described previously.2 Several education programs lost recognition after attaining it because of staff turnover. Low reimbursement rates from Medicare for diabetes education services were frequently identified as problematic in implementing and sustaining these services.4 In addition, federal reimbursement policies for designated rural health centers limit the abilities of these practices to bill for education services.9 Both of these issues were described in Arkansas as the state fostered and funded diabetes education sites in rural areas.2 Nonetheless, primary care practices in Montana have been enthusiastic about the enhanced skills and education resources available locally. Individuals in Arkansas also described the lack of consistent data collection about diabetes care and education as a barrier to their efforts. To address this need, the Montana DCP developed a diabetes education module as part of the statewide diabetes care quality improvement registry.10 Seven education programs are using this software program to monitor education services provided to their patients. It was also found that the IHS criteria for education recognition differed somewhat from the ADA criteria, and the submission process was not electronic. However, integrating IHS and tribal sites into the overall program was relatively straightforward because both recognition programs seek to document education according to the same national standards.11 In conclusion, Montana's QDEI is an example of a successful partnership between a state diabetes control program and MAADE. This relatively low-cost collaboration can be used as a framework to increase both the skills of health care professionals in diabetes education and the access to quality diabetes education in a rural state.
The authors would like to thank and acknowledge the volunteer mentors who dedicated their time and effort to mentor other health care professionals in Montana and the many diabetes educators across the state who provided support to developing programs. We also thank Susan Day for her assistance with this program. In addition, we thank and acknowledge Blanche "Dolly" Bronzini for her guidance and technical assistance regarding the American Diabetes Association's Education Recognition Program. Finally, we thank the Montana Diabetes Advisory Coalition for their recommendations to develop this program and their ongoing support. This program was supported through cooperative agreement U32/CCU822743-01 with the Centers for Disease Control and Prevention (CDC), Division of Diabetes Translation. The contents in this report are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
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