Implementation of Evidence-Based Disease Self-Management Programs in a Rural Region: Leveraging and Linking Community and Health Care System Assets

Abstract

Context

Rural populations experience both a higher prevalence of and risk for premature death from chronic conditions than do their urban counterparts. Yet barriers to implement community-based chronic disease self-management programs persist.

Program

The Living Well program, a multi-sector collaboration between a rural health care system and a network of community-based organizations, has offered the 6-week evidence-based Chronic Disease Self-Management and Diabetes Self-Management workshops since 2017. The program was a response to a quality improvement initiative to improve hypertension and diabetes outcomes throughout the health care system.

Implementation

Using the rapid cycling quality improvement process, Living Well developed a self-management program recruitment, referral, and coordinating office for a six-county region. Through continuous capacity-building efforts with community partners, as well as leveraging key health care system assets such as the electronic health record and provider detailing, program reach and adoption was increased.

Evaluation

The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used for the process evaluation. During 3 years, more than 750 individuals engaged with the program, with nearly 600 completing a workshop. The region saw increased engagement by primary care clinicians to refer, and structural changes were embedded into the health care system to facilitate clinic–community partnerships.

Discussion

A coordinated, multi-sector approach is necessary to develop solutions to complex, chronic health problems. A regional coordinating hub is an effective strategy for implementing community-based programs in rural areas. However, low health care system engagement and fragmented funding remain as barriers to optimal implementation.