Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural...

Area of Science:

• Community Health
• Diabetes Prevention and Management
• Health Systems Research

Background:

• Traditional community diabetes strategies are ineffective due to poor alignment with community systems.
• A novel community-driven process using local data and rapid prototyping is proposed.
• This case study examines improving diabetes outcomes in two rural Nebraska communities.

Purpose of the Study:

• To describe a community-driven process for developing tailored diabetes prevention and care management solutions.
• To provide baseline data for a 3-year initiative focused on improving diabetes outcomes.
• To test the hypothesis that decentralized decision-making fosters sustainable local solutions.

Main Methods:

• An iterative design process was employed, with community coalitions acting as innovation hubs.
• Local data feedback and monitoring were central to the facilitated design process.
• Six core diabetes measures were tracked via electronic health records from community clinics.

Main Results:

• Baseline data revealed two-thirds of the population in both communities are at risk for prediabetes.
• Prediabetes screening rates were low, with only 35% and 12% of at-risk individuals screened.
• This finding prompted coalitions to prioritize improving community screening rates.

Conclusions:

• Effective diabetes outcome improvement requires stakeholders to have continuous access to accurate feedback for informed decision-making.
• Conventional implementation of evidence-based interventions is insufficient for complex system change.
• Community-driven, data-informed processes are essential for optimizing health systems.