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Heartland Rural Health Network

  • Need: To assist diabetic patients in rural Florida with chronic disease management.
  • Intervention: Heartland Rural Health Network set out to expand the Diabetes Master Clinician Program and implement healthy eating in 4 Florida counties.
  • Results: Initial participating clinics exceeded national averages of successful management of diabetes. The program remains active and successful.


Promising (About evidence-level criteria)


According to the American Diabetes Association (ADA), only 30 to 45% of patients with diabetes achieve one or more of the ADA goals for quality indicators associated with hemoglobin A1C, low density lipoprotein cholesterol (LDL), and blood pressure (BP). Furthermore, only 7% of patients achieve goal levels in all three indicators at any given time. Yet according to Dr. Ed Shahady, a co-founder and medical director of the Diabetes Master Clinician Program (DMCP), "people who are able to effectively control their diabetes over time have fewer strokes, fewer hospitalizations and less blindness and kidney failure."

The DMCP is a registry that was established to improve the quality of diabetes care with information on things such as HgbA1C and body mass index. This registry was originally a program of the Florida Academy of Family Physician Foundation, but now is under the Diabetes Master Clinician Program, Inc..

Heartland Rural Health Network logo Heartland Rural Health Network (HRHN), along with the Florida Department of Health-Highlands County and 3 consortium clinics, set out to expand the evidence-based (DMCP) in 4 rural Florida counties. The end goal for the HRHN was to increase chronic disease management within the service areas.

Aside from expanding the DMCP model, HRHN incorporated the use of community health workers (CHWs) and the Healthy Eating for Successful Living in Older Adults model. In addition, HRHN planned to implement a 4th model for its project, the telemedicine application of remote monitoring, but due to setbacks was not able to develop the model.

The program received original grant support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant. Today, the program continues through a grant from the Florida Blue Foundation, continuing the CHW portion of the original program.

Local practitioners continue to refer uncontrolled and newly diagnosed diabetics to the CHWs. As with the previous program, the CHWs provide an important link between the providers and the patients, sharing information both ways to increase patient outcomes. Patients meet with their CHW on a one-on-one basis at least 6 times. During their first meeting, CHWs give a pre-assessment evaluation to determine diabetic knowledge, physical activity level, and self-care skills. With this information, paired with information from the provider referral process, the CHW tailors meetings with each client to provide the most comprehensive education and support as possible. After the 6th visit, CHWs provide the post-program assessment and each client's progress is tracked. CHWs work with referring provider to gain a pre- and post-hemoglobin A1c test.

Services offered

During the active grant period, the following services occurred:

  • Nutritional educational services for 1000 clients
  • Community events and health fairs nutrition distribution of over 900 educational pamphlets
  • Specific nutrition programs at 10 locations with a total of 100 participants
  • CHW community-based case management services included health screenings, referrals, and monthly visits to assess barriers and achievements in participants' diabetes care
  • DMCP data registry reports provided to both patients and providers to monitor health indicators


Given the setbacks for data accumulation and observation during the initial grant period, all reported results began in the 3rd quarter of the 2nd grant year. Out of the 5 clinics reporting, only 3 clinics participated throughout the full 3-year grant period.

Initial results demonstrated:

  • All HRHN healthy eating programs reached target goal of 75% completion or more with 1 site reaching 100%
  • 21% of participants reached quality indicator goals in clinics with full grant period participation
    • Though not participating for full grant period, one clinic saw 19% of participants reach quality indicator goals
  • CHWs averaged 113 clients per month
  • Total annual savings for all patients that met at least 1 ADA indicator was $891,312

More recent results under the new grant:

Year one:

  • 158 unduplicated patients referred, with 96 electing enrollment
  • 476 CHW client visits
  • 42 clients completed at least 6 visits
  • 50% of those completing the program increased weekly physical activity as measured by pre/post assessment
  • 95% of those completing the program increased diabetes self-management knowledge as measured by pre/post intervention assessment

Year two results as of September 2017:

  • 105 unduplicated, new patients referred, with 62 choosing enrollment
  • 542 CHW client visits to new and established clients
  • 71 clients completed at least 6 visits
  • 48% of those completing the program increased weekly physical activity as measured by pre/post assessment
  • 93% of those completing the program increased diabetes self-management knowledge as measured by pre/post assessment
  • 14 of the 71 completing the program also logged a pre- and post- Hemoglobin A1c with 79% (11 of 14) showing improvement as measured by post 6th-visit results

Heartland Rural Health Network is also featured in RHIhub's Rural Health Promotion and Disease Prevention Toolkit.

For more information, see also the HRHN feature story was in the summer 2014 issue of Rural Health Information Hub's Rural Monitor.


During the initial grant period, the HRHN program had three different program directors resulting in gaps for baseline figure reporting and data collection. Also, archival data from the DCMP registry was unavailable. Another factor impacting results came from one organization closing during the last year of the project, causing the overall program to reduce participating clinic numbers from seven to three during the grant period. These barriers brought limits to the initial program results.

Due to unexpected cost, dissatisfaction with contracts, and patient referral issues, the telemedicine application of remote monitoring program was not launched.


HRHN found that the initial cost to setting up a telemedicine model can be expensive and complex, especially true for programs relating to diabetic health.

Diabetes test strips and certain strips required for the remote monitoring product were also costly for those without insurance coverage.

Communication between CHWs and providers is key and having a structured referral system allowing communal flexibility of CHWs leads to improved outcomes.

Contact Information

Melissa Thibodeau, Executive Director, Executive Director
Heartland Rural Health Network, Inc.
863.452.6530 Ext. 305

Chronic disease management
Community health workers
Wellness, health promotion, and disease prevention

States served

Date added
October 20, 2015

Date updated or reviewed
November 21, 2017

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.