Dian True, RN, MA, CDE, (pictured) travels long distances to deliver individualized and group patient care, provide medical supplies, and teach diabetes self-management in Wyoming.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

Wyoming is home to places like Jackson Hole, the Grand Teton mountain range, and of course Yellowstone National Park - the first U.S. national park and one of the country’s biggest, natural treasures. It is easy to find peace and solitude taking in the environmental beauty within this part of the country. While Wyoming is the tenth largest U.S. state in terms of geographic area, it is the least populous, according to Wikipedia.

The state also offers majestic, peaceful plains that are perfect for expansive cattle ranches that run for miles across the state. However, with its vast landscape, comes challenges for these ranchers and Wyoming’s rural residents. For example, being isolated from larger communities can be difficult when these people get sick and need to receive medical care.

To understand the nature of the health challenges associated with people living in rural and isolated areas, UCLA recently wrote a paper about the subject for rural seniors who live in California. UCLA researchers took data from a 2007 state health survey, and concluded that, “California`s more than half a million rural elders are far more likely to be overweight or obese, physically inactive, and food insecure than their suburban counterparts… All three conditions are risk factors for heart disease, diabetes, and repeated falls - conditions also more prevalent among rural elders.” There were a number of reasons for these findings including a lack of practitioners nearby so seniors had to drive long distances for medical care.

Fortunately, for the people of Wyoming, there are diabetes educators like Dian True. She is someone who personifies what it means to be a dedicated diabetes medical professional practicing in a rural environment. True works at the Billings Clinic, which is a not-for-profit healthcare organization with numerous satellite facilities. True is based in Cody, Wyoming, a small town of approximately 11,000, and is about 50 miles from the eastern entrance of Yellowstone National Park.

And while True sees patients in her clinic most days, she also spends a lot of time traveling so she can deliver diabetes education to patients in need. Armed with a Powerpoint projector, medical supplies, and self-management literature, True travels once or twice a month driving up to 100 miles away to outlying clinics. She and the diabetes team also helps to support 20 primary care practitioners, six of the seven diabetes specialists in the state who practice at the Cody site, and helps to deliver care at the local hospitals too.

DiabetesCare.net recently sat down with True to discuss some of the challenges associated with delivering medical care and diabetes education to a mostly rural population. Here are some of the highlights from the conversation:

DiabetesCare.net: You provide support for 20 physicians across Wyoming. How much geographic territory would you say you cover overall?

True: We cover about 100 square miles. We are the only American Diabetes Association’s (ADA) certified clinic in northwest Wyoming. There used to be two, but we had one of our sites close last year, so we have picked up those patients too. You don’t make money doing diabetes education; you hope to break even.

Typically, people will drive up to 90 miles to get here to the clinic. When they come to town, they do their banking, grocery shopping, and all of their appointments.

We have huge working cattle and animal ranches here, and a lot of our patients who live 40 to 60 miles away come on a semi-regular basis.

DiabetesCare.net: How often do you travel to see patients?

True: We travel about once or twice a month, and about every third month, we do regional diabetes education. When we do these, we travel to different areas to provide both a morning and an afternoon class to different clinics about 50 to 100 miles from us. We send our patients to those clinics for these education sessions.

We also cover the local hospitals too. For example, I was at the hospital yesterday morning at 6am making rounds, before I came to the clinic. Sometimes I go there after being in the clinic all day, or at lunch - depending on what the doctors’ needs are.

My partner, Liz Fabrizo, MS, RD, CDE, and I spend several times a week in our car coming and going. Still, it is good thing. We have the same team servicing the same region. We have all been together for about 10 years now. We are all very flexible and we can help each other out.

DiabetesCare.net: Can you provide an overview of what you bring and what your day is like when you travel to outlying clinics?

True: We have to take everything we need, because we are not going to run back to the clinic when you are 90 miles away. Sometimes we will take meters and strips to those clinics. We take educational things like the ADA’s, Living with Diabetes book. This way, people can go to their local clinics for everything.

Sometimes before or after a class, Liz or I will go see a specific patient at the clinic if they are starting on insulin. We usually do a morning class at one site, and then we go to a second site in the afternoon.

The other clinics know when we are coming, so we do whatever they put on our schedule. We will teach a class and see some patients. We remain flexible. We usually do this on a Friday, and on Monday we finish all the paperwork.

DiabetesCare.net: You had mentioned that certain times of the year, like February, make it impossible to travel to see people. How do you use technology to overcome weather and distance challenges?

True: Several of our facilities are set up for telemedicine access and we are part of the regional network. Patients can go to their clinics and phone into us. When their clinic does not have telemedicine access, we use the phone, e-mail, and faxes a lot. For example, with patients’ blood sugars, we review them first and then get on the phone and talk to them.

For many of our patients on insulin pumps, they download their insulin pump information on the computer then we can get on the phone and talk. Telemedicine has been a huge help to us not only for our diabetes patients, but we also use it for our cardiology and oncology patients, who would otherwise have to drive many miles for medical appointments.

DiabetesCare.net: What are the other big challenges of providing diabetes education in a rural area?

True: We don’t have some of the things that others take for granted. We do not have 24 hour pharmacy service. You have to get your medicine between 9am and 9pm here. We are near Yellowstone Park, and when the park closes so does Cody.

Another big challenge is insurance and seasonal employees. One of our big hotel groups will go from 50 employees in the winter to 350 in the summer, and these employees usually do not have insurance. Unless you work for the few places that have insurance like the hospital, the schools, the county, or the state, there are a lot of people that do not qualify for insurance. About 50 percent of our patient population is underinsured or uninsured. We have a lot of patients who do self pay like our ranchers.

DiabetesCare.net: How do you overcome reimbursement challenges?

True: The biggest challenge is matching resources. We are sensitive to what people have in terms of insurance, so we spend a lot of time with coordination of care.

For the people who are self-pay, we are careful how we see them, including maybe doing a little more phone follow-up.

We also have a community clinic for the uninsured, which is not a free clinic but grant-funded. Sometimes we’ll do a self-management session at the clinic one night; we’ll just donate our time. Then people don’t have to pay for education.

DiabetesCare.net: What are the greatest rewards to providing diabetes education in a rural setting?

True: When I started our diabetes education program in 2000, we were only the second program in Wyoming, and there were only 5 educators. Now there are seven ADA certified sites and about 50 of us (educators).

I worked at a big diabetes program before, and when I came here, there were no programs. I had the pleasure to be the founding president of the Wyoming Diabetes Association of Diabetes Educators (WyADE) and sat on the Wyoming Diabetes Control and Prevention Board. We as a group have worked very hard to help the state diabetes program partner up with the smaller sites to develop the network and help it grow to where it is today.

In 2006, Wyoming Association got their national charter from AADE. We have brought education to all the communities that we serve.

We host one of the biggest diabetes conferences in the state for our physicians, nurses, educators, and pharmacists. Every year we have between 60 and 100 people come to the conference. We inform our physicians and our education partners so that the quality of care continues to improve.

I sat on the Wyoming’s Department of Health’s Diabetes Prevention and Control Board for 10 years and I just retired in January. Everyday, I see the care our patients receive; they are more empowered to take care of themselves.

We are not seeing as many foot and leg problems, nor heart attack and stroke victims. Patients are coming to the clinic more routinely for what I would call wellness care then for sick care. That means you have improved their quality of life and you can’t replace that. I feel privileged to be a part of the changes that have happened here.

Originally posted by DiabetesCare.net on July 1, 2011.