St. John's Regional Medical Center
Joplin, Mo.

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St. John's Regional Medical Center and its partners implemented a three-year, three-component program to improve meaningful access to health care, increase the health literacy of its patients with Type II Diabetes, and partner with them to make long-term life style changes.

Collaborate for Self-Management Improvement in Diabetes (CSI Diabetes) was designed to ensure that people with Type II Diabetes were knowledgeable about their health and empowered to play a central role in their care and self-management. The short-term goal was to ensure that people with Type II Diabetes are knowledgeable about their health and empowered to play a central role in their treatment. The long-term goal was to reduce the rate of emergency room visits and hospital admissions for persons with Type II Diabetes as their primary or secondary diagnosis. The center's population is from Southwest Missouri and has approximately 58 percent residing in the Joplin area, 42 percent living in rural areas and 6 percent non-English speaking Latinos.

Access to basic primary health care is a major barrier in Southwest Missouri. According to the Missouri Department of Health and Human Services, more than 36,631 people in St. John's service area are uninsured and lack health and dental insurance. Social demographics correlate highly with the ability to access health care. The per capita incomes in the area are much lower than the state's per capita income. According to the 2000 census, the area has experienced a substantial population increase. There has also been nearly a 20 percent increase in adults living below the poverty line and more than a 10 percent increase in persons under age 18 living below poverty level. Additionally, the population mix is changing. The Hispanic population in Southwest Missouri grew by 354 percent between 1990 and 2000 (the largest increase in the state) and continues to grow rapidly.

Diabetes screenings, self-management education, skills training and case management are provided at no charge to patients diagnosed with Type II Diabetes at the free clinics in Joplin and the FQHC clinics in Anderson, Mo., and Joplin, Mo. These services were not being offered previously. The CSI team of a Registered Dietitian (RD) and a Registered Nurse (RN) provides initial assessments, short and long-term goal setting, group diabetes education, and support groups. On-going case management support, as well as other specialty support, is offered to all participants. All participants are scheduled for face-to-face follow-up meetings with the CSI team every six to eight weeks to check on how they are progressing on the set goals and clinical measures.

CSI Diabetes has four major accomplishments: collaboration, clinical outcomes, data tracking and analysis, and financial outcomes. The program is a true collaborative effort with four community clinics serving the uninsured and the underinsured. Patient education and case management services are provided to clients at their primary medical homes. The CSI Diabetes staff work in close collaboration with clinic staff to refer patients to the diabetes program and to refer its clients for further clinical treatment of other co-occurring conditions such as high blood pressure, depression, etc. It is also linked with community partners including optometrists, pharmacies and the YMCA to provide other services. All educational and instructional material is available in Spanish and a medical interpreter is used for all non-English speaking patients.

This collaborative chronic disease management model has enabled clients to have dramatic improvements in blood glucose levels, weight management, and blood pressure. Longitudinal data on 164 participants show a significant reduction (P = .001) in A1C (8.2 to 7.5). With the implementation of our weight management class and participant goal setting, 86 patients have lost a total of 878 pounds. Blood pressure is also down, with 57 percent of our clients now having blood pressure within normal limits. In order to track data longitudinally, a patient/service database was developed specially for the program to efficiently analyze data. The database also allows for calculation of the hospital's cost avoidance data. Cost avoidance analysis demonstrated that hospital costs were reduced by $163,084. According to WebMD the annual cost to treat a person who has uncontrolled diabetes is $10,000. So, potentially, an additional $2,030,000 in health care resources was saved.