U.S. Department of Health and Human Services
National Diabetes Education Program Logo

Contact Us

Health Information Center


 Alternate Versions


 Additional Links


 For More Information



Case Study 7: Introducing Diabetes Education Services in Rural Communities

Gretchen Piatt, Ph.D.


The key goal of the Healthy People 2010 diabetes focus area is to increase the proportion of people with diabetes who receive formal diabetes education.1 A common challenge in meeting this goal is generating referrals for diabetes outpatient education services.2 To address this problem, the University of Pittsburgh Diabetes Institute (UPDI) implemented the Chronic Care Model3 in a number of primary care practices in rural communities just outside of Pittsburgh, Pennsylvania.4 The goal was to defragment the health system and restructure it to be evidence-based, population-based, and patient-centered.

Team members

Primary care physicians, office staff, and three CDEs (2 nurse CDEs and 1 dietitian CDE) are available on designated “diabetes days” in each of 17 primary care practices. The CDEs rotate to different offices based on their schedules.


To increase referrals for education services, the UPDI began in 2003 to deliver diabetes self-management education (DSME) at the point of service in the primary care office setting. The program started with four primary care practices and expanded to 17 throughout southwestern Pennsylvania. Decision-support tools, including the American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes5 and the National Standards for Diabetes Self-Management Education6 were used by team members to provide consistent care and benchmarking to allow for clinical evaluation efforts. All DSME sessions used an empowerment approach to diabetes education, and clinical and behavioral outcomes were collected for each patient.


The CDEs met with the local practice physicians and their office staff to determine the best methods for communication and documentation within the practice and to arrange their appointment schedule.

Insurance coverage

Previous efforts have established that payment for DSME is critical in generating revenue to support the services of CDEs. In this setting, the CDEs secured ADA recognition for each of the 17 primary care sites and were then able to bill for their services in the primary care setting.


Individuals who received DSME, both at the point of service and in traditional outpatient education settings experienced significant decreases in mean A1C levels over time (point of service DSME: 7.6 percent to 7.3 percent, p<0.0001; traditional DSME: 7.0 percent to 6.7 percent, p<0.0001); however, it must be noted that those who were referred to point-of-service DSME had higher baseline A1C values and may have represented people who needed more-specialized attention. The same pattern was observed in LDL-cholesterol levels. Individuals who received DSME at the point of service had significant declines in LDL (118 mg/dl to 101 mg/dl, p<0.0001). This decline was larger than was observed in individuals who received traditional outpatient DSME (116 mg/dl to 107 mg/dl, p<0.0001).

Related references

  1. U.S. Department of Health and Human Services. Healthy People 2010. Washington D.C. U.S. Government Printing Office, 2000.
  2. Balamurugan A, Rivera M., Jack L, Allen K, Morris S. Barriers to diabetes self-management education programs in underserved rural Arkansas: implications for program evaluation. Preventing Chronic Disease. 2006; 3:1–8.
  3. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Millbank Quarterly. 1996; 74:511–544.
  4. Siminerio, LM, Piatt GA, Emerson S, et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. The Diabetes Educator. 2006; 32(2):253-60.
  5. American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes Care. 2011; 34(Suppl 1): S11–61.
  6. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care. 2007; 30(6):1630–7.

February 2013