ArticleJournal of general internal medicine2023
New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals.
Article in Journal of general internal medicine, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
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The trial behind it
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Who cites it
5 citing papers in PubMed, 9 citations in OpenAlex.
- Using Health Information Systems to Support Behavioral Interventions in Local Contexts: Scoping Review.JMIR medical informatics · 2026Review
- A Two-Way Text Messaging Intervention to Narrow Disparities in Patients With Type 2 Diabetes and Poor Glycemic Control.Diabetes spectrum : a publication of the American Diabetes Association · 2025Article
- Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.Journal of community health · 2024Article
- A Systematic Approach to Treating Early Metabolic Disease and Prediabetes.Diabetes therapy : research, treatment and education of diabetes and related disorders · 2023Article
- Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy.Journal of general internal medicine · 2023Article
Corrections and comments
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Authors and funding
11 authors at 3 institutions in 1 country.
Funding
Abstract
backgroundRural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services.
objectiveDetermine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. DESIGN/
participantsQuality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services.
interventionSMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). MAIN MEASURES: HbA1c, blood pressure, and LDL over time for each study group. KEY
resultsOf the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05).
conclusionThe SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.
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