The burden of diabetes impacts minority, low-resource, and at-risk or distressed populations disproportionately. The Health Extension for Diabetes program, a community-based diabetes self-management support program, was established from an Extension-clinical partnership serving participants living in either at-risk or distressed communities. The goal is to provide participants with evidence-based information about diabetes, promote and facilitate social support within the group, and provide resource navigation. Through increased Extension-clinical collaboration, participants have received community-based education that supports the American Diabetes Association’s Standards of Medical Care. Additionally, access to clinical care in at-risk or distressed communities has been increased, thereby allowing for improved health and accompanying outcomes. By continuing to leverage Extension-clinical partnerships across the country, other communities can benefit from collaborations that expand evidence-based health education.
According to the American Hospital Association, a vulnerable population has one or more of the following characteristics: lack of primary care services, poor economy, high unemployment, limited resources, high rates of lack of insurance, cultural differences that pose challenges for accessing medical care, low education or health literacy levels, and environmental challenges.1 Many of these characteristics are commonly seen in areas of the Upstate of South Carolina. Greenville County was identified as a primary county of interest for targeting health education programs to improve access and health outcomes. Other risk factors for vulnerability that present at both a local county level and a state level are the rural areas that lack healthcare centers and public transportation and require long-distance travel to primary care and hospitals.2
Populations that experience these obstacles are identified as vulnerable so that community health agencies and healthcare systems can focus on providing them the resources and care they need but may not be receiving. Health resources can be anything from referrals to medical or education classes, food assistance, or other physical and social support groups. The barriers faced by most rural communities prove especially detrimental to the elderly population when they attempt to access healthcare resources. A focus group study was performed in six rural West Virginia counties to identify what barriers older adults faced and what assistance they needed to better manage their health and access more resources.3 Two of the most frequent barriers discussed were transportation and social isolation. A characteristic of many rural cultures is the idea of self-reliance and a reluctance to seek medical care, especially when long-distance travel is necessary.3 According to a Pew Research Center study, the average travel time to a hospital for people living in rural areas is seventeen minutes compared to only 10.4 minutes for people living in urban areas.4 Social isolation results from rural norms, and without knowledge of public transportation or accessibility to resources, people remain isolated.3 A solution to overcome these barriers resulting from the focus group study was disseminating information to the community to increase awareness of available resources.3 Clemson Cooperative Extension Service in South Carolina is strategically poised to meet this need to better serve and improve community members’ lives because it includes a Rural Health and Nutrition (RHN) program team. The program team has Extension Agents with related health, public health, and nutrition backgrounds located in priority counties across the state. The agents serve as content experts for chronic disease prevention and self-management, as well as policy, system, and environmental changes. Community resource navigation skills are leveraged to connect community members with services such as transportation, health care, social, financial, and other resources.
Community Outreach and Recruitment
The RHN program team aims to help community members live a healthy lifestyle through chronic disease prevention and self-management. In the Upstate of South Carolina, the Health Extension for Diabetes program provides community-based diabetes education and support to vulnerable communities.
Vulnerable communities are identified and targeted for outreach using data from the Economic Innovation Group’s Distressed Communities Index. This index ranks counties and zip codes as prosperous, comfortable, mid-tier, at-risk, and distressed.5 Analyzing this data and incorporating it into the recruitment process allows the delivery of evidence-based information related to diabetes self-management and other chronic conditions to participants who may not otherwise receive the education or support resources needed to better manage their health.
The Centers for Disease Control and Prevention states that the best way to provide education and information is through a joint effort between public health, community, and healthcare sectors in the form of public health initiatives, community support, and equal access to quality health care.6 Extension Agents on the RHN team form relationships and work in conjunction with community health workers, certified diabetes care and education specialists, dietitians, social workers, senior centers, etc., to best reach and provide education to community members. The collaboration provides programming and referrals to the community-based education programs and reciprocal referrals and increased clinical services awareness. Healthy initiatives and community support develop from the relationships formed with these partners.
Program recruitment uses traditional Cooperative Extension methods, such as leveraging relationships with community members and stakeholders. This involves working with existing Extension partners and forming new community partnerships with healthcare systems and other social and health resources providers. Some of the barriers that can hinder or prevent diabetes education in communities are lack of referral from healthcare systems, affordability of classes, lack of transportation, convenience for location and time, and misperception of the benefits. Clemson Cooperative Extension Service is able to bridge a gap in the community to overcome these barriers by providing an evidence-based education program without the requirement of a physician referral. While the program has a great clinical linkage for out-of-scope situations and questions, it is designed to be delivered by a non-clinical professional. The programs are offered in easily accessible locations in the communities, such as in community centers and neighborhoods, and at convenient times.
Resource Navigation for Increased Access
Many people interviewed in rural areas state they are not aware of programs and services available within the community and are unsure where to begin the search to find resources.7 Due to their knowledge and partnerships with healthcare systems and providers, Extension Agents act as resource navigators in urban and rural areas to promote healthy lifestyle behaviors for chronic disease prevention and self-management and instill empowerment. Translating technical information in applications is another benefit that agents provide. There may be plentiful resources in urban areas, but some may find it challenging to access resources and understand the qualifications for assistance. It can also be difficult for resource agencies and frustrating for those in need if there are wait times or other obstacles that create delays due to more people trying to access the same resources. There may be fewer resources to navigate in rural areas, but the same barriers related to understanding access and qualifications exist. Additionally, barriers such as transportation and even the availability of specific resources resulting from food deserts may exist. Overall, an application process could be challenging based on a person’s education level,7 and agents can help translate technical information.
Social determinants of health, including health care, education, socioeconomic status, and more, influence an individual’s ability to access care beyond the physical barriers. Financial barriers in vulnerable populations can lead to a delay in visiting a primary care physician and an inability to pay for necessary medications. People in vulnerable populations may be forced to choose between food, medication, or other health devices such as a blood glucose monitor. The Department of Health and Environmental Control states as of the period from 2016 to 2018 that a little over fourteen percent (14.4%) of Greenville County residents have delayed seeing a doctor over the past year due to cost.8 Diabetes medication and monitoring can require a multitude of supplies that can be financially burdensome, even with insurance. Extension Agents can identify lower-cost pharmacies, medications, and supplies, as well as social service benefits. Resources for social service benefits include housing assistance, Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and other food assistance programs.
One of the current leading problems within the US healthcare system is the lack of integration between different systems and institutions in the healthcare field.9 This leads to individuals being seen and treated for the same conditions and issues multiple times by a variety of institutions and physicians. The duplication of services can occur when individuals visit outpatient care, a clinic, urgent care, the emergency room, etc., for recurring issues that could be prevented. The focus in those settings is then placed on short-term goals providing immediate relief and release of the patient from care rather than long-term health changes.9 Through a multidisciplinary team of health and community systems such as a Cooperative Extension Service, social services, and other local healthcare systems, those in need can be helped efficiently while optimizing resources.
Efficiently integrating systems of care for community members is important because it prevents duplicative and unnecessary uses of healthcare resources while saving time and additional expenses for community members utilizing those health centers. According to a research study regarding hospital emergency department visits in South Carolina, at-risk populations of African Americans and Medicaid patients reported higher frequencies of urgent and nonurgent visits to emergency departments.10 African Americans were also visiting emergency departments for health issues that had high primary care preventability scores.10 These statistics provide insight into the issues that can arise from inadequate access to healthcare resources such as primary care physicians and lack of education on what constitutes an emergency department visit versus other non-emergency forms of care.
Lessons Learned from an Extension-Clinical Partnership
One of the most important benefits derived from the Extension-clinical partnership is the relationship between the Extension Agent and clinical staff, including certified diabetes care and education specialists. Although the certified diabetes care and education specialists are not present at every class and do not provide clinical oversight, the Extension Agent has a clinical linkage for clinical questions that arise during a program. This clinical linkage offers ongoing access to evidence-based information that would not typically be available in community settings.
Extension Agents also can facilitate clinical referrals to formal diabetes self-management education, Medical Nutrition Therapy, and other health services through the healthcare system. Of the insured population eligible for diabetes self-management education, only between five to seven percent receive it.11 A goal of the Health Extension for Diabetes program is to increase the number of eligible people receiving formal diabetes education from a clinical educator by utilizing the referral process for the participants.
Lastly, it should be acknowledged that the Extension-clinical partnership provides greater reach within the community. Partnerships with a local healthcare system allow for referrals into a community-based program and information to be disseminated through office, clinic, and hospital locations, expanding the potential reach in the community. In addition, the process of reciprocal referrals not only provides participants with better access to and awareness of clinical services, but it also provides those receiving clinical services access to community-based resources. Individuals receiving clinical services may face barriers to continued clinical services or may need additional services within the community to supplement their clinical care. Primary care physicians are the coordinators for their patients’ health, which means they are a great resource to share Extension-led and community-based program information with their patients, specifically those who need diabetes self-management support.12 Receiving information about community-based health education programs offered by a local Extension Agent from a healthcare provider can also facilitate trust between the Extension Agents, participants, and clinical partners.
The Health Extension for Diabetes program exemplifies the value of leveraging an Extension-clinical partnership to better serve community members, especially in vulnerable and at-risk communities. The program’s primary goals continue to be providing evidence-based education, social support, and resource navigation for community members to manage their health and prevent complications. The RHN Extension Agents use traditional Cooperative Extension values of providing unbiased, research-based information to educate and navigate current social, clinical, and financial resources for community members. By integrating a variety of available resources into the education and support that Extension Agents provide for participants, community members are more informed about support and resources available within the community. The Extension-clinical partnership has provided a mutually beneficial and more extensive network of resources to benefit the community. Continued education and support and continuous delivery of accessible resources for the community are how an Extension-clinical partnership works to provide integrated care while avoiding the duplication of efforts from the larger healthcare system.
- Bhatt J, Bathiia P. Ensuring access to quality health care in vulnerable communities. Academic Medicine. 2018 Sep [accessed 2020 Apr];93(9):1271. doi:10.1097/ACM.0000000000002254.
- Vulnerable populations: who are they? American Journal of Managed Care. 2006 Nov [accessed 2020 Apr];12(13): S348-S352. https://www.ajmc.com/journals/supplement/2006/2006-11-vol12-n13suppl/nov06-2390ps348-s352.
- Goins RT, Williams KA, Carter MW, Spencer SM, Solovieva T. Perceived barriers to health care access among rural older adults: a qualitative study. The Journal of Rural Health. 2006 Jun [accessed 2020 Apr];21(3):206–213. doi:10.1111/j.1748-361.2005.tb00084.x.
- FACTTANK News in the Numbers. Washington (DC): Pew Research Center. 2020 [accessed 2020 Apr]. https://www.pewresearch.org/fact-tank/2018/12/12/how-far-americans-live-from-the-closest-hospital-differs-by-community-type/.
- Distressed Communities Index. Washington (DC): Economic Innovation Group; 2020 [accessed 2020 Apr]. https://eig.org/dci/methodology.
- MMWR. Health disparities experienced by Black or African Americans – United States. Atlanta (GA): Centers for Disease Control and Prevention; 2005 Jan 14 [accessed 2020 April]. 54(01);1–3. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5401a1.htm.
- Horton S, Johnson RJ. Improving access to health care for uninsured elderly patients. Public Health Nursing. 2010 Jul [accessed 2020 Apr];27(4):362–370. https://doi.org/10.1111/j.1525-1446.2010.00866.x.
- South Carolina County Health Profile. Columbia (SC): South Carolina Department of Health and Environmental Control; 2020 [accessed 2020 Apr]. https://gis.dhec.sc.gov/chp/.
- Chandra A, Acosta J, Carman KG, Dubowitz T, Leviton L, Martin LT, Miller C, Nelson C, Orleans T, Tait M, Trujillo M, Towe VL, Yeung D, Plough AL. Strengthening integration of health services and systems. In: Building a national culture of health: background, action framework, measures, and next steps. Santa Monica (CA): RAND Corporation; 2016. [accessed 2020 Apr]. p. 99-121. www.jstor.org/stable/10.7249/j.ctt1b67wjh.16.
- American Diabetes Association. Diabetes. Lifestyle management: standards of medical care in diabetes – 2019. Diabetes Care. 2019 Jan;42(Suppl. 1):S46–S60. doi:10.2337/dc19-S005.
- Chen BK, Cheng X, Bennett K, Hibbert J. Travel distances, socioeconomic characteristics, and health disparities in nonurgent and frequent use of hospital emergency departments in South Carolina: a population-based observational study. Bethesda (MD): BMC Health Services Research; 2015 May [accessed 2020 Apr]. 15, Article number: 203. doi:10.1186/s12913-015-0864-6.
- Bodenheimer T, Lo B, Casalino L. Primary care physicians should be coordinators, not gatekeepers. Journal of American Medical Association. 1999 Jun [accessed 2020 Apr];281(21):2045–2049. doi:10.1001/jama.281.21.2045.