SMART: Diabetes and Hypertension Education and Outreach Program

The Diabetes and Hypertension Education Outreach Program targeted the rural, minority, and medically underserved communities in Bradford, Dixie, Gilchrist, Hamilton, Levy, Suwannee, and Union counties in Florida. Mostly rural in nature, the region spans approximately 3,900 square miles, with a population density of 38 people per square mile.

Each of the three core network members initiated subcontracts with a case manager who traveled to clients’ homes to provide home-based self-management education on effective care for diabetes or hypertension. Specifically, the case managers provided tailored, home-based educational sessions on the causes, risks, and management of diabetes or hypertension; individual counseling; and case management. The project also conducted community health screenings to identify individuals with pre-diabetes and prehypertension and provided patient education, newsletters, and follow-up calls to clients discharged from the program.

Although not an innovative service delivery model, homebased education is an ideal and simple way of delivering care. The program met clients where they were, allowing case managers to get a realistic sense of how each client lived.

Participants learned about this program via physician referrals. Once enrolled, the case managers delivered 12 hours of home-based disease management education over 6 to 12 weeks. Once the education component was complete, case managers made quarterly follow-up calls or visits to track blood sugar and blood pressure levels as well as any hospitalizations or deaths attributable to the client’s disease. During the follow-up phase, participants were reminded to receive annual eye, dental, foot, and hemoglobin A1C exams. In addition, the annual community health screenings provided an opportunity to identify individuals at risk for diabetes or hypertension and to determine whether those at risk have a regular source of care. All project services were provided free of charge.

An initial barrier in getting the program started was the apprehension of local physicians over a new program in the community. Some physicians even refused to meet with project case managers to discuss the program. However, once residents heard how well the case managers treated their patients and how knowledgeable they were about diabetes and hypertension, potential clients began asking their physicians for referrals.

Another step that similar projects could take to generate more community “buy-in” early on in the program would be to recruit case managers knowledgeable of diabetes and hypertension management from the target community. This approach would help the program to quickly establish a sense of trust with residents.

Due to insufficient funding to sustain the program at its previous level, the project has reduced its staff from three full-time to one full-time and two part-time case managers. Through the support of local providers, foundation dollars, Federal carryover funds, and other agency donations, the program will continue providing outreach and education services at this reduced level for another 2 years.