Diabetes Management in Rural Health Care Settings and Technological Advancements

At the Core of Care

Published: December 13, 2021

SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities. 

I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.

As part of our Housing is Health series, we’re going to spend this episode learning how a rural health care program in North Dakota manages its diabetes prevention and treatment program across four different communities. Our conversation will touch on the use of telehealth, patient education for self-management and access to care obstacles that patients might sometimes encounter around technology and transportation.  

Our guests Rhonda Pfenning and Janet Wanek work together at the Coal Country Community Health Center in Beulah, North Dakota, a city of 3,000 people. Coal Country is a federally qualified health center and operates four different clinics throughout North Dakota.

Rhonda Pfenning is a registered nurse and certified diabetes educator. And Janet Wanek is a licensed registered dietician nutritionist.

Welcome Rhonda and Janet to At the Core of Care.   

JANET: Thank you. 

RHONDA: Thank you. 

SARAH: Just want to start off by saying that we happen to be recording this conversation during National Diabetes month. And the theme of this year's awareness campaign is pre-diabetes and preventing diabetes. Rhonda, can you start us off talking about how your nursing career led you to specializing in diabetes education and prevention?  

RHONDA: Sure. My path with nursing is probably not unlike a lot of other folks. I started a little bit later in life. And I went back to school when my daughter was in the first grade. And I’ve had my nursing degree for going on 30 years and started out in long term care until my daughter was diagnosed with type one diabetes at the age of 11. And that that kind of turned the tables for me and as I worked in the nursing home, because my daughter was diabetic, I guess the other nurses assumed I knew what I was doing, which I didn't. So I literally learned by trial and error and literally have been working with diabetes for 25 years in some way, shape or form. And so when I started working at the clinic as a chronic care nurse, this evolved almost immediately into the diabetes education role. And so I took a couple years to get the education and the training that was necessary to get my CDC, yes. And for the last three or four years, Janet, I can't remember how long we've been working together. But we've been getting our nose to the grindstone trying to get this diabetes self-management education program and the diabetes prevention program, two separate programs off the ground and running and we've been doing pretty good. We've been working hard. 

SARAH: And Janet, what led you to become a dietitian?  

JANET: Well, if I'm being honest, I became a dietitian because of one of those career aptitude tests we all took around junior high. And one of the career choices came back as a dietitian. So around that time, I job-shadowed a dietitian. I then talked to a distant cousin of mine who was a dietitian and probably around the age of 14, yeah, this is something I'm going to do. So my whole high school path was in the health education kind of components. And I went to college in and out in four years to get my dietetics degree. And the path that has kind of led me to do the diabetes and prevention. And the diabetes prevention program at Coal Country kind of evolved from becoming a lifestyle coach outside at a previous job on top of being a dietitian, and really helping to fill that kind of community education role. And I've really always enjoyed doing the community education piece. So that was kind of an easy fit. 

SARAH: So much of the outreach in the diabetes space is centered around empowering patients, right, to learn how to reduce their risks, change behaviors make healthy choices. What are some common patient behaviors in the communities you serve, and that you're trying to help patients learn to manage? 

RHONDA: The floor is yours, Janet. 

JANET: Okay. Maybe one of the biggest things that you see as any kind of common patient behavior that you're trying to overcome when dealing with any chronic health condition, it has to do with communication skills, their understanding of the disease process. Are the patients ready to take charge of their diabetes? Are they willing to overcome some barriers, including a communication flaw with family or friends or at social situations where they might be turning down foods everyone knows they love. Or when they need to start shopping differently, or plan trips around a pharmacy. And rurally that might be 30 miles away. And it really takes opening up about your disease and communication, so you can make sure that your needs can be met by what needs to happen. I think one of the biggest flaw or common behaviors that you run into is people just aren't willing to talk about it. And when you don't talk about it, you tend to not make those big life changes that you need to overcome that barrier of making changes to help you manage your diabetes. 

SARAH: So can you walk us through the process of someone who might just be starting a diabetes education program? What does the initial appointment consist of? And what kind of treatment plan do you develop? 

RHONDA: First of all, we need a referral. The whole process starts with a referral. And what Janet and I teach here, we have two components, or two tracks that we teach. One is diabetes self-management education. And the other is diabetes prevention. So there are two separate roles, two separate tracks. And we need a referral to start with them. We make an appointment to see the patient. Her and I work together, we kind of tag team initially. And I focus more on what's going on inside the body, the disease of diabetes, what happens over time, and what's going on inside the body hat can harm you. And explaining what an A1C is, because most people have heard of it, but don't really even know what it is. So that's where I start.  

And, you know, there's a lot of things we work on. You know, Janet takes care of the healthy eating. We both work on being active. You know, they have new equipment, like maybe a glucometer that they've never seen before. They'll have new medications, possibly, you know, what are the side effects, learn when to take on? What's the best way to problem solve? If like Janet said earlier, talking to your family, how do you tell them that you have diabetes, and what do you have to do about it? Reducing risks such as being able to exercise and put that in your plan and keeping your sugars under, you know, in a good place so that you don't develop side effects. The nasty ones that everyone hears about, from when we were kids, you know, going blind and that type of thing or losing your legs. And working with patients to help them accept where they are, make decisions on their own, so they make the best decisions for themselves and continue on to live a healthy and happy life. Janet is the food guru. And so I leave all of that to her. 

JANET: If I can just add a little piece of that. After you receive that referral from whoever their primary care provider is, you know, telling them about why you should come to diabetes self-management education program. They really encourage someone come to the program anytime they've been newly diagnosed. Anytime they're changing medications. Anytime that they're just not meeting the management of their diabetes. And from there, you really have to treat every patient kind of individually and see where they are at their level of knowledge. So they kind of have this assessment component when you first start, of just general baseline knowledge. What do they know about diabetes? My general go-to question and I mentioned this earlier to Rhonda is, hey, there's five food groups. There's dairy, there's protein, there's fruits, there's vegetables, and there's the grain group, which one of them contains carbohydrates? And you'll be surprised just from that one question, their understanding about the nutrition component. And you can easily do that, you know, with an A1C level, what did that A1C level mean to you? Or if you had a family history of diabetes, did you ever see a loved one take insulin? What did that look like to you? And just getting a general assessment of what that person knows about the disease itself? That preferably is not from a YouTube video or social media of some sort, right. That it comes out from their general knowledge. So that's a big piece, too, to develop a plan going ahead. 

SARAH: I'm curious, you know, before we move forward, just in terms of you talked about sort of individualizing the treatment. And I know, obviously, you have clinics that are serving different communities. Are there things that you find in terms of talking with different patients, either in the different centers or different clinics that relate to kind of the communities that they're coming from, the culture that they're coming from? 

JANET: The one thing that really comes into my mind is, you know, we serve four different rural communities, because that's where our clinic sits. Now, Rhonda, and I live in two completely separate communities that this clinic isn’t in, in this rural part of North Dakota. And I jump to that nutrition component where I just updated a lot about meal services offered in all of these communities. So somebody might jump to or hear of something called Meals on Wheels, where seniors or different people have access food right to their doors normally during the week. Now, I live in a community that doesn't have that. And Rhonda lives in a community that doesn't have it. The three of our four communities where the clinics are have a Meals on Wheels program, but one doesn’t. So just the access of services depend on your different location for something even for food programs, or food pantry access in some of these communities aren't even there. You know, not to use the food desert term, right? I didn't come up with that term. But truthfully, there's a lot of communities that we live in that could probably be classified as food deserts. And that's just where my head jumps to, for how you might differentiate care based on our communities.  

RHONDA: Janet, you live close to an Indian reservation as well. 

JANET: Yep. And that was going to be my next part is the cultural component. And there is a pretty active diabetes program up on the Indian Reservation, the Mandan, Hidatsa, Arikara Nation, right north of me, I’m only about 15 miles off the reservation. And their programs are really active and they’re always trying to see the components of social media, and that playing off. But that piece of the reservation that really is kind of served on our site is really removed. They're like maybe a couple 100 people, and they're maybe an hour and a half away from their nearest dialysis center, right. Like they're really, really removed. So we see a lot of that reservation who come to our clinics for care, and we'll run into them as well. So knowing culturally, you know what their four winds spirit food wheel looks like and knowing some of their traditional foods and maybe religious or cultural components that might be limiting when they eat or different fasting days and there's a very interesting piece that can be played, or that you have to think about when you're talking to some of those people as well.

SARAH: And certainly this series is focused on housing is health, right. So thinking about, it really, really does come down to where you live in a lot of ways. The access that you have to food. The access that you have to these services.  

So, in the past managing diabetes heavily centered on finger pricks, right, to measure blood glucose levels. But now there's more and more using continuous glucose monitoring devices. And we'd love to have you just explain kind of, in plain terms, how that works. And then also, we're aware that patients can also use a smartphone app to even record their levels, and maybe that you could even read their levels remotely. So just kind of walk us through that. 

RHONDA: Oh, my gosh, yes. This has been my new baby for the last year so. Literally, when COVID started here in our area, and patients were not coming in, we, through the public health emergency, I happened to be reading on the ADA website one day. And I found out about continuous glucose monitoring and some of the changes that were coming about, along with telehealth, of course. So I really started looking into the opportunity of getting some patients on it while they were at home. And that's how this all started. So continuous glucose monitoring, it's been around for a long time, but it's really just kind of taken off in the last probably two years in the United States that I've ever seen. But It's a piece that you wear, two pieces of equipment that you wear right on your skin. There's a little catheter that sits right underneath your skin, that tests your body fluids. So it's different than your blood glucose. So it's testing your body fluid instead of your blood. So that's the difference. However, everything being equal, when there's, you know, if you're not eating or you're not exercising, those numbers are really similar. And so what we're getting now is the ability for a patient not to stick their fingers four to five times a day, which is what they were doing, which is time consuming, it's painful, it's costly, all that stuff. And putting a little button or a little, you know, a little piece on your stomach and taking a device like a reader.  

So each of the CGM, the continuous glucose monitoring devices have their own reader, or you can use your own cell phone and download an app, it's just as simple as that. And you scan and you get a number. It's so cool. You can set it up to alarm you, when you go low, alarm you when you go high. You can remind yourself when to check your glucose, when to give your insulin. It's so simple, the technology, is very simple to use. And I would say over 80% of the people that I have in this rural area that are using it are Medicare age, which is phenomenal. And I'm impressed on one end about the amount of technology that people do understand with cell phones, yet, that you still have the others who don't even own a cell phone, you know, so you've got both ends of the spectrum that you're working with. And the technology is really nice. If you don't have your cell phone, you come in the clinic will download your report, send it right to the docs, they can look at it and make decisions based on that. If you have a cell phone, it's real time info, just go onto the program. And we can literally talk on the phone like I did with a patient who is wintering in Arizona. So I called him on the phone and asked him how he was doing, pulled up his report. And we discussed what was going on right there. And yeah, we made some decisions based on his sugars. And it was really cool. So it doesn't matter where you are. We can work with you. That's exciting. 

JANET: I was just going to add the only hiccup that I've had, truly, when you're talking about being able to download or, you know, use the devices is email addresses. So in order to link all that data to set up an account, some people still in our area, don't use email or have email addresses to upload that information to. And that's how you log in and build accounts for a lot of the continual glucose monitors and blood fingerstick monitors as well. You set up that data based off an email, and we still run into some of those. So truly, then it is bringing in the actual physical monitor reader to download and plug it into a computer because they just don't even have an email, and they don't want any footprint out there in the data world online. So you still have a little bit of that as well. 

SARAH: Yeah, that really is amazing. And so the patient too, they would be able to spot glucose patterns. And theoretically, would they be able to use that to manage their own behaviors? 

RHONDA: That's exactly right. And that's what I'm finding. And so when we're teaching them how to use this system, it's using that empowering their own skills, teaching them what to look for. And one of the first things do is I tell them, you know, go eat your favorite food and eat as much as you want. And watch your sugars, you know, scan, scan, scan and watch your sugars. And I hear back from people time and again, this is so amazing, because what I'll do is I'll scan, and that'll make the decision for how much food I'm going to eat at my meal. So I don't go over. So I stay in my goal range. And I see the positive results from the patients because their A1Cs go down. They're happy because they have done it themselves. They feel like they've accomplished something because they can literally see it minute by minute. So it's really been a positive reinforcement for anyone that's been using it. 

JANET: And I know another piece of that whole thing is when they're looking at the big picture, and they're seeing their numbers and what they're actually doing, they might end up using less insulin and less medication. And having less other health complications that come up, you know, more infections happen if our blood sugars are running higher, including bladder infections or UTI urinary tract infections or skin infections. So you see them maybe save money on insulin. You see them having to go to the doctor less for some of those acute things, or maybe even preventing chronic complications. And in the end, that's going to save them money in their pockets. So, you know, in the whole big picture, them wanting to keep track. And doing that scanning and see what their sugars are actually doing in real time is a great way to help them manage their diabetes. 

SARAH: And given that you're working in a rural healthcare setting where we know transportation, talking about long travel times, those can really be real barriers to care. So how have you seen continuous glucose monitoring impact that, you know, has that been a game changer in terms of the access to care, transportation issues? 

RHONDA: Absolutely a game changer. What I do here now in the last year is, again, we're creating a new path for what we're doing for our patients. But the end result is they are succeeding, they are doing it themselves. And that's what's most important. They have the tools to do the job. And that's with anything that you do. If you understand what that number means. And you have the tools to do the job. And then you succeed. It's a win-win-win situation. And I'm seeing that over and over and over. One of the things that I found since doing this is that most people who come to the clinic, and had good A1Cs, quote unquote. When you run the libre report, because you get to see 24 hours a day, you find that a lot of times they're on too much insulin. And that has been really an eye opener for me that, you know, this is the old world where the provider season a fasting number in the morning, and then maybe a blood sugar before you eat supper. And you base your whole diagnosis and what your insulin is based on those two readings that are just a spot in time. Now we have a 24 hour picture. So when they make a decision, it's based on fact. It’s pretty cool. No guessing anymore.

SARAH: And clearly, this is empowering for the patient. And you're putting the tools in the hands of the people who are best positioned to make those changes. But it's also time saving. So I mean, how much of your time are you spending on patient education about the apps? You know, how does that look in terms of you know, downloading the app and the technology piece? 

RHONDA: It takes takes about probably 15 to 20 minutes to train them on how to use it. I usually help them download the app while they're sitting here doing that. And that is maybe five to 10 minutes, and then everything else we do on the phone or we visit. And when I do call them, because there are some patients that have just started on insulin. I literally call them on the phone and we say what is your reader telling you? Let's go in the history and break down what's going on with you and your blood sugars. And so everything is based on what their actual numbers are on a 24 hour day. It's really innovative. 

SARAH: And Janet, from your perspective, how does the education piece look? 

JANET: I think with everybody, it's so individualized because you are going to have the patients who still don't even understand the reader and how is connected or not connecting. So there's some people that when they have it, they're off and running right away. But you do spend a little bit of time troubleshooting their technology device with them. And that's true of any technology device, I remember teaching a technology class at one point in my life on bring your own device, and I'll troubleshoot it with you. So you do have some of that. And you'll always have some of that, but the people pick up on it right away, pretty soon, you can show them how you can put in the time that you're giving your short acting insulin right on there. You can put little apples on the screen for when they're eating their meals. So then when they are looking at the report, they can even see more of a better picture by using those little icons. And oh yeah, so that's when I started to trend up. And that's when I started to trend down. Or here, I went too low, did I give my insulin at the wrong time. And you can see all of these little pieces, if they use the applications. And they know how to use the applications a little more and more each time. But normally, you just start out, this is how you scan. And with that component, you have the ones who are off and running, and they're reading the manuals, and they are loving every minute of it, or you're having the other ones come back in and you're like did you know it does this too? Did you know it does this too. And it's really a good way to keep the education going with them on how they can help themselves by this one little technology device. 

SARAH: So obviously, we're talking a lot about these different tech advancements. And I know that there have also been technological advancements on the insulin treatment side. And certainly the shift to pumps instead of injections. So can you walk us through that? 

RHONDA: What I'll say is that it's getting better every day. One of the biggest hurdles we're facing right now is the public health emergency. And so there's a lot of manufacturers that have pumps waiting to be approved by the FDA. But COVID has really been the most prominent and prevalent thing, and everything else has kind of taken a backseat. So all this new and exciting technology that they've been telling us about for over a year is still sitting at the FDA. But what's really cool is that there's pumps out there now that you can set right on your skin right beside your CGM. And your continuous glucose monitor talks right to your pump. You don't need to be in the middle of it. So that's the coolest thing. You set your high and you set your low, and your pump uses the algorithm to say, oh, give give me a little more, give me a little less. And so it's just getting better and better all the time. The technology that's waiting to be approved doe use, you should be able to run your insulin pump on your cell phone. So that is coming. That's really cool. So yeah, we're excited to start working with that.

JANET: But something you do have to consider is you run the possibility of having a patient who might bring you in four different electronic little devices, right. So you have the little device that runs your insulin pump giver. You might have the little device that tells you what your continuous glucose monitoring system has had for all of its blood sugar readings. You might have a finger stick device, because there's still possibility of checking your finger sticks in between to calibrate a continuous glucose monitor to make sure what it's telling you is pretty accurate. And then they have their own cell phone where they might be storing all of this data all in one spot. So you might have a lot of technology thrown at you with one specific patient. And then there is a huge learning curve that might come when you're talking about all of that with somebody or if I am a new care provider and somebody brings me in four different devices going ‘What is all of this and how do I get all that information off of that there?’ It can be a little overwhelming if you're not used to thinking about all the little pieces that might be incorporated with that technology to help you manage that diabetes or your blood sugars. 

SARAH: And we've seen this technological advances across the board. Certainly over the course of the COVID 19 pandemic, there's been, you know, of course a major switch to telehealth everywhere. Given that you're working in a rural health care setting, were you in any way prior to the pandemic providing some of your care through telehealth?  

JANET: One thing I like to remind people who might not know this is we work at a federally qualified health center. to the whole COVID-19. In the public health emergency, federally qualified health centers, you had to be one on one with the patient in order to get paid for seeing that patient. There was no remote patient care, there was no virtual health visits. We weren't even allowed to do group classes like most diabetes, self-management, education is done in groups. But a federally qualified health center, you cannot do a group class, it is all one on one. So now let's switch gears and now prior say, but we don't want people who are healthy coming into a clinic that might be seeing people during a pandemic. So we need to open up our rules a little bit. So with the public health emergency, they opened the doors for telehealth, and at our federally qualified health center that gave us the ability to do this diabetes self-management education, one on one virtually in the Zoom world. We're all getting more apt to using our computers for things and that is a great way to still get that patients one on one diabetes self-management education tool without having them to come in with our diabetes prevention program.  

So the Center for Disease Control had programs that you could sign up to be an in-person site, virtual site, online learning site or have a mix site and Coal Country Community Health Center was an in-person site. The only time a federally qualified health center can have a group class was for diabetes prevention program. Well now we weren't allowed to have group classes with a pandemic, so that all got moved to the virtual world as well. So it really kind of opened up this whole new world of how to get education with good programs, with certified programs, with CDC recognized programs with programs recognized by the American Diabetes Association more widely accessible and I really hope they don't ever stick that band-aid back on. 

SARAH: And we've heard that echoed from so many of our guests, right, the silver linings, the innovations that have come from the COVID 19 pandemic. Let's make sure that we're that we're learning from them, that we're continuing to get those advantages. And so obviously, you know, with the various locations, you are still providing transportation to patients in need within I guess a certain radius of the clinic. Can you tell us about that? 

JANET: So where we work at in Beulah, we serve probably a 25 distance, 25 mile radius. So they have a transportation van that goes right out to the patient's home, pick them up, bring them to the appointments and we'll take them back home. They're working on getting a second van at our farther location. So from where we work in Beulah, North Dakota, and Kildare, North Dakota is about 50 miles away. And right now they're working on getting another transportation van to serve that area of North Dakota, which is closer to the Montana border. So we'll even have a farther expansion of transportation through Coal Country Community Health Center to go and pick up some of these rural individuals and bring them to the facility for care, which is great. Because I see this quite often as a volunteer on the ambulance as well that sometimes non-emergent people just don't have a way to get safely to a doctor's appointment or clinic appointment. So they call for non-emergent reasons to try to get somewhere. And it happens and having that access to transportation is huge for our rural community and elderly community and just safety in general for help managing some of these health things. And telehealth has really helped open that picture to do remote patient monitoring and check in on patients remotely is a big, big difference too, in these rural communities. 

SARAH: And while most of the work you do is in Beulah, how often are you traveling to the various clinics? 

JANET: So of the four clinics sites that serve for the diabetes self-management education program, we go to three of them. We are primarily located at Beulah but we go to Kildare, North Dakota, which is closer like I said to the Montana border. And then we go to center, North Dakota, which is about 40 miles to the other side. So from I describe it from center, North Dakota to kill deer in North Dakota is about 100 miles away from each other. And that's on the straight roads, right? That's not as the bird flies or the crow flies. But if I took roads, it's probably 100 miles from one clinic to the other clinic. But we go to our rural clinics, those two clinics at least one day a month.

SARAH: So you had mentioned earlier the Native American population and how they access your clinics? Is there additional outreach to that community, to the reservation? Like how, how does that access? Look? How do they know about you? How do you learn about them? How do you make those connections? 

JANET: The actual MHA nation has a very active diabetes self-management program as well. And I know the two individuals who run that program, and they do great social media outreach, there is still a clinic on this side of the water kind of closer to where we live, but it's only open two days a week. So right now, I don't know if this programs ever heard of the chronic care management program as well. So you kind of call monthly check in. So some people up on the reservation, I know do utilize our chronic care management program. So through our clinic, right and using those pieces, but they do have an act of Indian Health Services with that clinic and some good providers up there too, that I am aware of. And I know they come over into their elementary school and they're doing activities and they have their own little senior Meals Program or their elder care meals program that I always share pictures with on social media sites to kind of remind people, they're still up there and active and try to encourage are doing a promotion right now to try to get them to sign up for their meal program. And I think a big part that we play through Coal Country is knowing these things exist for them, because you still run into people not knowing that, you know, they have an elder care meal program or that they have the services available to them. Because if you don't ever, you know, promote yourself or promote the work that others are doing that is similar to your work right? We kind of forget about health promotion of all of us doing trying to serve the same picture. So it's kind of nice to know all of those resources.

SARAH: So we're coming to the end of the conversation. Would love to hear any final thoughts that you'd like to leave our listeners with, as they’re thinking about rural healthcare, running programs that are, you know, really focused on patient education. But I'd really say around patient engagement, because that's really what you're describing here, too is, is that education that really empowers the patient to improve their own health outcomes. So any lessons you've learned things that you really want to make sure that our listeners take away? And let's pass it to Rhonda first.

RHONDA: When I started doing this umpteen years ago, the doctor gave the patient a pill and told them to come back in six months. And then they’d come back in six months, and their sugars were worse. And so the doctor said, We'll take another pill, and then we'll see you again in six months. So that was all their education. That was all they had. 

We are working really hard to give them the tools to succeed every day. What is really cool is when people come in and just are so excited about themselves, that they have to come in and say hi. Or they'll just drop in and hand me their cell phone and say, Please download this for me, and how am I doing today. And so you not only engage the patients to take care of themselves. But the other takeaway is you build a trusting relationship with them that's ongoing. And so when I work with patients, and Janet does this too, we work with them as a dietitian and a nurse. And I work with them as a nurse and a diabetes educator. And I also work with them as a member of this chronic care team, and so does Janet. So we're engaging in different areas and different levels. And so the whole thing comes back to the patient feeling like they have control, that they can talk to you when things aren't going so good. And they don't, they're not going to get chewed out, they're going to learn about, you know, let's try it this way and see what happens. And you've got him for life. And that's the important thing is that they're taking care of themselves. And you know, down the road, they don't probably see it today, but they'll still experience the end result of having a healthier life in the long run.

I grew up in this area. And so this culture is a people that don't talk about their illnesses. We keep it to ourselves. We don't tell anybody if we have a problem, because we don't want anyone to know that there's something wrong with us. We don't like to talk about, you know, the cause of diabetes might cause depression. You know, the different things that go along with that. You don't talk about that. So when we're in here talking and you can evoke some of those responses back about how's that making you feel? It's really surprising what is out there. And you can go so far. Sometimes you can't delve too deep, but that's when you do the individual assessment in, you work with what you can and try and help them succeed no matter what. 

JANET: My only parting comments that I want to kind of leave with is I came to Coal Country Community Health Center in 2018, not ever being a full part of a diabetes self-management education program. And if you're just getting started with it, and you're trying to build either a diabetes self-management education program at your facility, or in the outpatient world, or you're trying to work on starting a diabetes prevention program at the facility you're working at, talk to other people who are doing it. However, I did find federally qualified health centers are not doing this in our region. So we are, I think, one of five federally qualified health centers in the state of North Dakota, and none of them have these types of programs. So you might have to reach out to a bigger picture. And if you ask the right questions, you might even start getting invited into conversations that help change the big picture as well. And I felt a little bit of that, like I asked so many questions about how does this work at FQHC? 

And that really opened up me into this whole new realm of sitting on different legislative panels with my nutrition and dietetics Association and becoming a nutrition services payment specialist for the state and really diving into the bigger picture of items, which also in turn help get the word out to know that these things are doable and hopefully will expand access to other people who are living rurally by not making other entities scared of trying it.

RHONDA: I’ve worked here, I don't know, I'm going on 10 years now. But I put the skeleton of the diabetes self-management education program together. And it was kind of just sitting there and running in neutral, kind of spinning. And when Janet and I got together, our personalities kind of synced. And what I lacked in, she had more of. And so between the both of us, we have gotten this program off the ground. We've created the billing elements for it, we have been able to become providers, schedule our patients, do the whole thing. You know, there's more always more we can do. But we've worked really hard to get where we are. And it's been a hard road. It's been fun. But you know, the whole goal is to see the smile on the patients’ faces. And when someone can get their sugars down and feel good about themselves. That makes me feel good, too. So it's been a lot of hard work, but lots of rewards.

SARAH: Rhonda and Janet, thank you so so much for making time for this conversation. It really was such a pleasure to hear the passion for your work and the impact that you're making on the patients that you serve. So thank you.

RHONDA: Thank you, Sarah.

JANET: Yeah, thanks for having us, Sarah.


SARAH: Funding for our special housing health series comes from a center to champion nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP and AARP Foundation. 

Special thanks to our partners through the National Training and Technical Assistance Program at the National Nurse-Led Care Consortium. 

For more about us and our programs, log onto  paactioncoalition.org and nurseledcare.org.  And you can connect with us on social media @PaAction and @NurseLedCare. 

At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.