Strategies to Improve Diabetes Control in Rural/Remote, Low-Income, and Uninsured Patients

1. Community Assessment: Rural/Remote living, low-income, and uninsured patients with diabetes Kailey Hamrick NURS 7350 7/24/13

2. Background • 1.2 million in USA have DM but not insurance • 55/67 of Alabama's counties are rural • Patients in rural/remote locations have less access to care, low income/uninsured can’t pay for preventative treatment/management • DM-related deaths: rural AL 25-44% higher than U.S. & 5-18% higher than urban AL • Goal statement: Determine what strategies may be used to better educate rural/remote living, low-income, and uninsured patients between the ages of 18-50 at the Bullock county health department on increasing diabetes control Nash, Reifsnyder, Fabius, & Pracilio (2011); Davidoff & Kenney (2005)

3. Assessment tool: a Survey 1. Do you live in Bullock county? 2. Do/Are you, -Monitor your blood sugar regularly? -Feel confident in your knowledge/understanding of diabetes? -Interested in learning more about your diabetes and ways to better control it? 3. Do you see a primary doctor/practitioner? -Office in your city? 4. Do you have health insurance? 5. Circle which category your yearly income falls into: (a) less than $24,000 (b) $24,000-50,000 (c) $50,000-90,000 (d) greater than $90,000

4. Survey Results • 25/30 live in Bullock county (rural) • 14/30 regularly check their blood glucose • 10/30 feel confident in their knowledge • 25/30 are interested in learning more • 12/30 see a PCP • 2/12 PCP office in their city • 15/30 have some health insurance • 18/30 income <24K, 11/30 income 24K-50K, 1/30 income 50K-90K, 0/30 income >90K

5. Factor 1 affecting health: Rural/Remote living • Nearly 20 percent of the American population • More difficult to ensure the availability of high-quality health services • Human resources and infrastructure are controlled by geography= challenges for patients, families, nurses, and health care providers The Future of Rural Health Care (2004) Sevean, Dampier, Spadoni, Strickland, & Pilatzke(2009)

6. Factor 2 affecting health: Low-income Gallup-Healthways Well-Being Index data • 57.2 for low-income Americans (<24K) • 67.7 score among the middle class (24K-90K) • 74.3 score among high-income Americans (>90K) Lower score: • <emotional and physical health, • < health habits • <access to medical care Mendes (2010)

7. Factor 2 cont’d:$ Low-income patients $ • >chronic conditions: depression, HTN, DM • < to eat healthy and exercise frequently • Smoking is > 3Xs the prevalence • Preventive care, effective treatment, and health > health and wellbeing, but they can least afford these and have the poorest access to health services • 1/3 low-income are uninsured • U.S. poverty rate 14.3% in 2009 • Food stamp recipient > 39.4 million January 41.8 million July • Less money for healthy foods (controlling weight and disease) Mendes (2010)

8. Factor 3 affecting health: Uninsured Patients • No insurance: < quality of life, > morbidity and mortality, > financial burdens • 137,000 adults age 25–64 died because of uninsurance(2000-2006), including 22,000 in 2006. (1 death every 24 minutes) • Relationship between uninsuranceand mortality • Adults age 55–64: increased risk of dying over an 8 year period from 7.5 percent to 10.5 percent. • No screenings and prescribed medication & skip recommended doctor visits= harm Dorn (2008)

9. Overview of factors affecting the overall health • Low income and lack of adequate insurance decrease access to healthcare & to education/medications needed • Lack of access to care (primary care providers) due to geography • Lower education levels decreases ability to understand symptoms, diagnosis, severity of diagnosis & treatments • Racial and cultural bias towards the selected population lead to disparities in healthcare

10. Health Disparities “Differences in the incidence, prevalence, mortality, and burden of diseases, as well as other adverse health conditions or outcomes that exist among specific population groups […] based on socioeconomic status, education, age, race and ethnicity, geography, disability, sexual orientation, or special needs.” Nash, Reifsnyder, Fabius, & Pracilio (2011)

11. Health disparities • Less access to quality preventative/diagnostic care/treatment • Racial, cultural, language, and religious bias from healthcare workers • Decreased faith in healthcare system by population due to biases • Higher burden of illness and lower quality of life • Lower income • Lower education level • Lack of or inadequate insurance • Less access to affordable health food • Lack of adequate/reliable transportation • Ex) Poorer patients have higher rates of avoidable hospital admissions Nash, Reifsnyder, Fabius, & Pracilio (2011)

12. population centered strategies for clinical prevention and/or health promotion • Enhance human resource capacity of health department • Increase cultural competencies of the healthcare workers • Identify population needs and shape education methods based on them -Ex) handouts in reading levels appropriate for education level • Enhance preparedness of patients to actively engage in improving their health and health care • Educate population, follow up, and evaluate the efficacy of the education and treatment, and adjust as needed. • Invest in an information and communications technology (ICT) infrastructure The Future of Rural Health Care (2004)

13. FINAL THOUGHTS • National Priorities Partnership & Healthy People 2020: eliminate health disparities, reduce disease burden, & increase quality & years of life • Rural/Remote living, low-income, & uninsured patients with chronic conditions= high health disparities and disease burdens • Imperative to examine this population, implement strategies, & decrease the disparities and disease burden Nash, Reifsnyder, Fabius, & Pracilio (2011)

14. References • Dorn, S. (2008). Uninsured and dying because of it: Updating the institute of medicine analysis on the impact of uninsurance on mortality. Urban Institute. Retrieved from http://www.urban.org/UploadedPDF/411588_uninsured_dying.pdf • Davidoff, A. & Kenney, G. M. (2005) Uninsured Americans with chronic health conditions: Key findings from the national health interview survey. Urban Institute. Retrieved from http://www.urban.org/UploadedPDF/411161_uninsured_americans.pdf • Mendes, E. (2010). In U.S., health disparities across incomes are wide-ranging: Emotional and physical health, health habits, and access to care worse for those with low incomes. Gallup. Retrieved from http://www.gallup.com/poll/143696/health-disparities-across-incomes-wide-ranging.aspx • Nash, D. B., Reifsnyder,J., Fabius, R., & Pracilio, V. P. (2011). Population health: Creating a culture of wellness. Jones & Bartlett Learning: Sudbury, MA. • Sevean, P., Dampier, S., Spadoni, M., Strickland, S., & Pilatzke, S. (2009). Patients and families experiences with video telehealth in rural/remote communities in Northern Canada. Journal Of Clinical Nursing, 18(18), 2573-2579. doi:10.1111/j.1365-2702.2008.02427.x • The Future of Rural Health Care. (2004, November 1). Quality through collaboration: The future of rural healthcare. Available from http://www.nap.edu/catalog.php?record_id=11140