North Country Diabetes Project

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North Country Diabetes Project

• Building Successful Rural Partnerships Utilizing
  Agency Niche to Meet Community Needs

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North Country Diabetes Project

• Goal- To improve the health outcomes and quality
  of life in individuals over the age of 45 years
  with diabetes or at risk for its development

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Clinton County, NY
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• 1118 square miles
• Population of 82, 047 (2005)
• Median Household Income 43,251
• 93 of population is White, non-Hispanic
• Persons over 65 represent 12 of the population

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Clinton County, NY
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Information from NYSDOH DPCP Diabetes
Surveillance in NYS, 2001
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Diabetes Services 2004-2005
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Barriers to Diabetes Services

• Community focus groups and physician surveys
  confirmed
• Medically underserved community
• Geographic Isolation
• Undertaking too big for one agency

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Needs Recognized

• Formal Diabetes Education Services
• Professional Community education
• A way to link people to services and community
  resources

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Identifying the Right Partners
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Partner Contributions

• CVPH Medical Center
• ADA recognition of DSME/MNT
• 288 MD referrals (15 w/5)
• 30 sessions (gt200 DSME participants)
• Average 125-150 MNT appointments per quarter

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Participant OutcomesPre to Post DSME
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Participant OutcomesPre to Post DSME
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Partner Contributions

• Clinton County Health Department
• Physician Network
• 25 participating Primary Care Physicians/
  Practices
• 2 rounds of office visits
• 300 local health professionals updated
• Community Campaign
• Attended/ provided over 100 community events
  (7,000 participants!)
• 6000 Diabetes Self Risk Assessments distributed
• 1300 Risk Assessments returned for evaluation

Weve got data!!!!
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Risk Assessment Data
Target Population
Participants Found at Risk
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Risk Assessment Data
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Diabetes Survey Data
Everyday I check my blood sugar
Everyday I exercise for 30 minutes
Everyday I follow my meal plan
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Partner Contributions

• JCEO
• 92 total rides provided, 45 participants
• 3,662 miles logged since 10/06
• 25 outreach workers in-serviced on diabetes and
  local resources
• 8 senior outreach workers received further
  training on Standards of Diabetes Care
• Diabetes Risk Assessment and information
  distributed from 12 outreach locations throughout
  the county

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Conclusions

• There is opportunity in rural communities to
  utilize limited resources and establish best
  practice programs
• Successful rural partnerships are possible!

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Diabetes Services 2006-2007
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• Mandy Snay, RD, CDN
• Public Health Nutritionist
• Clinton County Health Department
• North Country Diabetes Project
• snaym_at_co.clinton.ny.us
• www.clintonhealth.org