ArticleDiabetes spectrum : a publication of the American Diabetes Association2025
Diabetes On Track: Redesigning Diabetes Management in Rural Primary Care.
Article in Diabetes spectrum : a publication of the American Diabetes Association, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectiveDiabetes remains an intractable public health problem, particularly in rural communities. The Diabetes On Track initiative returns control of designing and implementing strategies to improve diabetes care delivery systems to the local clinics and community partners. This article reports on protocol development and the first 18 months of the Diabetes On Track project within the health care setting. RESEARCH DESIGN AND
methodsUsing a rapid-cycling quality improvement approach, the research team partnered with two rural clinics. Clinics completed a strengths and needs assessment before being offered a menu of possible strategies to implement. Clinics worked with the research team to implement, refine, and adapt these initial interventions and develop further strategies based on local data that were continually collected and shared. Six core indicators were established as primary outcome measures. Process measures were established based on the strategies chosen.
resultsBoth clinics decided to create a registered nurse health coach position to provide diabetes education to individuals with or at risk for developing diabetes. Both clinics also chose to implement a physician dashboard highlighting diabetes-related indicators so clinicians could track panel improvement over time. Other interventions included using a prediabetes outreach list and taking advantage of professional development opportunities, including a diabetes-focused Project ECHO (Extension for Community Healthcare Outcomes) series.
conclusionImproving diabetes care in rural communities is a challenge, and novel solutions are needed, with a focus on sustainability. The Diabetes On Track initiative is showing promising results, allowing primary care clinics to use community knowledge and data to redesign effective diabetes care delivery systems.
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