Better diabetic care: Bringing care to rural communities

Sometimes it’s a knock on the door that can make all the difference.

That’s one of the findings that MUSC researchers are touting now that the preliminary results of the Bamberg Diabetes Transitional Care study, funded by the National Center for Advancing Translational Sciences, are in: Rural residents with diabetes do significantly better with increased outreach support.

Dana Burshell, study coordinator at the Medical University of South Carolina, said even though she knew barriers to health care in rural areas exist, it was an eye-opener to witness the extent of the challenges. “They are such a population in need,” said Burshell, who is the program coordinator of community engagement with the South Carolina Clinical & Translational Research Institute's Center for Community Health Partnerships. “Everybody, not just a few, had major life barriers,” she said. “I feel like this study is a story of people who often don’t put themselves first and struggle to better manage their health.”

Prevalence of Diabetes in South Carolina

Diabetes is the seventh leading cause of death in South Carolina, and more than 15 percent of residents in Bamberg County have the disease. This is a rate more than 1.5 times the national average and 1.2 times the South Carolina average. Even worse, in Bamberg County the county hospital closed in 2012, and other than very busy primary care providers, there is no self-management education and support for people with diabetes.

In 2012, Bamberg County residents invited academic researchers to brainstorm solutions that would work in their community.  The resulting community-engaged feasibility clinical trial tested two interventions. Participants with uncontrolled diabetes received either calls from a local nurse interventionist or in-home visits from a local community health worker.

Searching for Solutions

The study, which started June 2014, was led by Carolyn Jenkins, DrPH, a professor in the College of Nursing at MUSC, and Samuel Cykert, M.D. a professor in the School of Medicine at the University of North Carolina at Chapel Hill. It was done in partnership with Brenda Williams from the Regional Medical Center of Orangeburg & Calhoun Counties. The South Carolina Department of Health and Human Services was a major source of funding for the project.

Jenkins considers the study, which involved 48 participants and concluded this month, a success on many levels. As part of the study, participants’ A1C levels, which show the average level of blood sugar over the previous three months and how well a person’s diabetes is under control, were pulled from their medical records. Preliminary results showed that with roughly half of the participants having a post-study A1C test, 58 percent of the participants in the community health worker group and 64 percent of the participants in the nurse group had improvements in their A1C over three months.

Preliminary data also showed improvements in self-reported depression scores for the majority of participants – 63 percent for the community health worker group and 60 percent for the nurse intervention group.

Medication adherence, a significant factor in diabetes control that decreases hospital readmissions and emergency department visits, also was studied. The study staff reported that when discussing medication adherence, it was more difficult over the phone and more helpful and interactive in person.  Over the course of the study, 50 percent of the community health worker group had an improvement in the participants’ self-reported medication adherence, compared to the nurse intervention group at 37 percent.

That’s just what Jenkins, her colleagues and community leaders want to hear. Jenkins, a strong advocate for community-based participatory research such as this, said the results reflect the importance of this type of community-directed research.

Diabetes in Bamberg County

Bamberg County is rural, with a predominantly black (61.1 percent) population and a median annual income of $19,000.  Jenkins said the study sprang from a grass-roots initiative, spurred by efforts of the Bamberg Diabetes Coalition, composed of community leaders and members and health care providers.  Important contributors included Mayors Blain Crosby of Bamberg and Gerald Wright of Denmark along with Leroy Davis, Ph.D., from the Voorhees College Center of Excellence in Rural and Minority Health.

Jenkins said this type of research goes beyond academic researchers calling the shots. It works because researchers and local leaders examine the community’s specific needs and make a plan that would work in that area. “The key is good science and community input and community ownership, because grants only provide the seed money. And communities end up needing to maintain these activities. So if you work with communities, the activities oftentimes last, and they grow or emerge into meeting the needs of the community.”

Having done this type of research for decades in all kinds of rural areas, Jenkins said she’s learned the importance of meeting people where they are. There are other benefits, too. “In working with the community, they have fed me, clothed me and even pulled me out of the ditch,” she said, recalling sliding off the road one rainy night in a dark rural area.

“It’s fun. I love what I do, and hopefully the community sees value in it. I like it when I hear people who say,‘We didn’t used to talk about diabetes. Now we talk about it. We used to keep it (diabetes) a secret, and now we share with each other. We get together, talk about it, and make plans for how to make it better. We walk together, we learn together, and we share our information with others.’ So the key is linking. Those linkages are so important with communities.”

Importance of Social Connections

Building up social connections is critical. Burshell said the majority of the participants had multiple, major life challenges. Study health care providers offered encouragement, diabetes education and practical interventions that participants said enabled them to prioritize their health and, in some cases, even be able to believe it was even possible to control their diabetes.

“Just the support of even the nurse on the phone and especially the community health workers who would say, ‘[My participant] dropped off the map. They’re not calling me back. I’m going to knock on the door and check on them,’ it just made a world of difference.”

Many participants attested to the effectiveness of structured support. “They said, ‘Despite all of the things in my life  - despite that I have to take care of my children and my mother, and I have to work 12- hour shifts that change every day, I have the support of people who make me matter and care and teach me objective things.”

Burshell recalls one participant who started the study slightly depressed and overwhelmed due to uncontrolled diabetes and an inability to be physically active.  Within three months, the participant’s A1C dropped from 11.3 to 8.5. She started doing chair exercises using canned goods as weights. Then she progressed to pushing a baby stroller around her neighborhood, and then to walking with a cane. She also used coloring books to decrease anxiety.

“This study is so compelling because the interventionists partnered with these participants and their families to find individualized, practical solutions,” Burshell said. “These were solutions that were realistic, sustainable and achievable – that hopefully will last long after the study ends.”

Jenkins agreed and praised the work of the locally hired community health workers, nurses and students, including Ramona Anderson, Horace Britton, Mary Brown, Lynn Glenn, Latasha Priester and Helen Sherman, along with community study coordinator Melissa Sherman. “It really made a difference in this project because we hired people from the community and worked together to learn.”

Jenkins said the next important step is to give the community feedback about the research. Study results will be shared with the Bamberg community through public forums, customized reports for participating practices and summary reports to all of the participants. In the next phase of the study, the participants’ hospital use over the upcoming year will be compared to a non-study cohort in the region to assess whether there are any decreases in hospital readmissions and increases in cost savings.

Impact of Diabetes Research

While community health workers and frequent patient follow-ups can be time-consuming, the ultimate economic impact for small primary care practices, hospitals and the government could be significant, Jenkins said.

Jeannie Davis, 73, said she didn’t even know what her A1C level was before the study. She never had taken a class on how to manage it either. She joined the study when she had to go to the Regional Medical Center’s Bamberg Urgent Care. Being part of the study has encouraged her to take her medication and keep track of her blood pressure. She exercises more and eats better.

“Knowing that Horace was coming, I had to always be ready and prepared,” she said of Horace Britton, her assigned community health worker. “I want to lose more weight and get and keep my A1C in check. I want to be off medication one day. I would participate again if I could.”