Objective

The purpose of this study was to assess the effect of an integrated system of coordinated care on chronic disease health outcomes of patients with poorly controlled diabetes, hypertension, and congestive heart failure (CHF) living in a rural area.

Design and sample

Longitudinal study of patients aged 18 years or older, living in a rural area, with diabetes glycated hemoglobin (A1C) > 8%, hypertension blood pressure (BP) > 150/90, heart failure, and suffering excessive weight gain and hospital admission in last 6 months.

Measures

Dependent variables were A1C, cholesterol, microalbumin, body mass index (BMI), BP, emergency department (ED) visits, and hospital admissions. Predictor variables included time in the program, age, sex, race, and Diabetes Self-Management Education (DSME) completion. Descriptive variables included telemedicine and specialty referrals and travel savings.

Results

Time had a significant effect on A1C, microalbumin, BP, and ED visits. Race, sex, and DSME also impacted A1C and BP outcomes.

Conclusions

Length of time in the program played a crucial role in improved outcomes for patients in the program for a year or more. Long-term, consistent reinforcement in the form of education and coordinated care provided by certified care coordination nurses achieve better health outcomes.