There are several strategies for sustaining diabetes prevention and management programs. The Rural Community Health Toolkit provides general information on sustainability in the following sections: Sustainability Strategies and Sustainability Strategies for Specific Issues.
Community partners play an important role in supporting the sustainability of rural diabetes programs. In some rural communities, partners provide in-kind resources, such as transportation to and from diabetes education classes, or physical space for program activities. Sustainability also depends on the ability of rural diabetes programs to continually engage new patients or participants. Building strong relationships with social services agencies, senior centers, community-based organizations, schools, and other community-serving institutions can help maintain steady referrals to program services. For example, the DFD Russell Medical Centers in rural Maine partnered with multiple community organizations to promote referrals to community resources, access to healthy food, group education classes, eye exams, and transportation.
Sustainable Funding Models
Time-limited grants may provide funding for initial investments in resources and staff and for ongoing support of program operations. However, many successful diabetes prevention and management programs also leverage payment and reimbursement from insurers to sustain program services.
Many private and public insurers cover services related to diabetes education, case management, and treatment. However, eligibility criteria for coverage differ across payers and states. Rural program planners may need to investigate local, state, and national policies for coverage of diabetes prevention and management activities to understand their options for billing and reimbursement:
- The Centers for Disease Control and Prevention (CDC)'s Diabetes Self-Management Education and Support (DSMES) Toolkit provides key resources for reimbursement and sustainability, including guidance for Federally Qualified Health Centers.
- The National Conference of State Legislatures provides state-by-state information about policies and coverage for diabetes prevention and management services.
- The Policy Surveillance Program offers an interactive map of health insurance coverage laws for diabetes self-management education and training.
Assessing the health insurance coverage among the community or patient population may help rural communities understand potential options for payment and reimbursement:
- Medicaid – While coverage varies from state to state, Medicaid programs typically offer coverage for diabetes medication, equipment, education (such as nutritional therapy), and self-management services. States are also exploring a range of other strategies to address diabetes, such as using Section 1115 Medicaid Demonstration Waivers to test new and innovative approaches to better serve Medicaid enrollees with diabetes. For instance, the Brazos Valley Care Coordination Program, which offered home visiting services to rural patients with diabetes, was funded by a Section 1115 Medicaid Waiver.
- Medicare – Medicare covers a range of services related to diabetes care and control. For example, Medicare covers prevention services for organizations that are enrolled in the Medicare Diabetes Prevention Program.
- Commercial/private insurers – Many commercial or private insurers offer coverage for services related to diabetes prevention and management. For example, in 43 states, private insurance companies are required to cover diabetes self-management education and training for enrollees.
Many private and public payers are testing alternative payment models, in which providers receive incentives to decrease healthcare costs, increase healthcare quality, and improve health outcomes. Requirements for receiving incentives could involve diabetes prevention and management, such as demonstrating a decreased rate of diabetes-related hospitalizations for the patient population:
- Arkansas Medicaid, the Arkansas Department of Human Services, Arkansas Blue Cross and Blue Shield, and QualChoice of Arkansas are participating in the Arkansas Health Care Payment Improvement Initiative. As part of the initiative, Arkansas is implementing a Patient-Centered Medical Home (PCMH) Program, which rewards providers for offering comprehensive and coordinated care. For example, SAMA HealthCare Services in rural Union County, Arkansas has increased their patient population and improved diabetes-related outcomes through participation in the PCMH program.
- Rural communities may also fund diabetes services through Medicare and Medicaid Accountable Care Organizations (ACOs), which refer to groups of hospitals and providers who work together to provide coordinated care. For example, the SERving PAtients-ACO in rural Nebraska receives incentives for meeting quality targets, such as an increased rate of patients with diabetes who receive an eye exam.
Leveraging Telehealth Capabilities
Many rural communities offer telehealth services for diabetes self-management services and education. There are many considerations for reimbursement for telehealth services. The American Diabetes Association also has information about changes in Medicaid and Medicare reimbursement policy for diabetes-related telehealth during the COVID-19 national pandemic.
Working with Policymakers and Payers
To achieve a sustainable funding stream for diabetes prevention and management services, rural communities may need to work with policymakers and payers to make changes in coverage for diabetes programs. The National Diabetes Prevention Program (National DPP) Coverage Toolkit provides strategies for increasing reimbursement for National DPP activities, including approaching commercial health plans and engaging state legislatures to advocate for Medicaid coverage. CDC has shared lessons learned from states seeking to attain coverage for the National DPP for state employees.
Resources to Learn More
Sustainability of Diabetes Self-Management Programs
Discusses effective sustainability strategies identified from a study of 14 sites involved in a diabetes self-management grant program funded through the Diabetes Initiative, a national program of the Robert Wood Johnson Foundation.
Organization(s): Robert Wood Johnson Foundation
Health Care Providers to Scale and Sustain the National Diabetes Prevention Program
Describes the sustainability efforts of PartnerSHIP 4 Health (PS4H), a coalition of rural counties in west central Minnesota that engaged healthcare providers and community partners to provide the National Diabetes Prevention Program (NDPP) to community members.
Organization(s): National Association of County and City Health Officials (NACCHO)
Prevention Program Toolkit – Module 4: Build a Sustainable Program
Describes the sustainability strategies and lessons learned from the Special Diabetes Program for Indians (SDPI), a diabetes prevention grant program focused on building a strong team that maximizes the skills and talents of individual members.
Organization(s): Indian Health Service (IHS)
Lists resources that provide strategies supporting the sustainability of community health workers (CHW) in diabetes prevention and management programs.
Organization(s): Centers for Disease Control and Prevention (CDC)
Diabetes Prevention and Self-Management Programs
An overview of the Healthy People 2020 national initiative focused on improving health and achieving health equity. Aligns the National Diabetes Prevention Program (National DPP) created in 2010 with a decline in the number of new diabetes cases in the U.S. Discusses the YMCA's experience supporting the sustainability of National DPP through reimbursement from third-party payers.
Organization(s): YMCA of the USA, Diabetes Advocacy Alliance, Office of Disease Prevention and Health Promotion
Early Results of States' Efforts to Support, Scale,
Sustain the National Diabetes Prevention Program
Discusses the activities, facilitators, and barriers to sustaining the National DPP for the prevention and delay of the onset of type 2 diabetes, as identified by program funded states during the first 3 years of a 5 year funding period.
Author(s): Mensa-Wilmot, Y., Bowen, S., & Rutledge, S., et al.
Citation: Preventing Chronic Disease, 14, E130