Okay, hi everyone, and welcome to today's Hands-on Tips to Improve Diabetes Care webinar. Today, our panel will share their expertise on addressing social and behavioral factors in diabetes care in rural populations, and we are glad you're here. I'm Marissa Hilliard, and I'll be moderating today's webinar. To share a little bit about myself, I'm a pediatric psychologist and behavioral scientist at Baylor College of Medicine and Texas Children's Hospital in Houston, Texas. My research focuses on strengths-based approaches to promoting health behavior change, quality of life, and optimal diabetes outcomes in people with type 1 diabetes and their families. I am the chair of the Behavioral Medicine Interest Group for ADA, and I am so pleased to be leading this webinar. We will spend the next hour together by following the agenda on the screen. We'll be using interactive features during today's session. We'll send you important links and information throughout the session in the chat box. We will have quiz questions throughout the presentation hosted on Zoom. When you see a quiz question pop up on your screen, take a moment to respond by clicking on the answer that you think is correct, and we'll be using Zoom Q&A at the end of the presentation for panel questions. If you think of a question as our presenters are speaking, use the Q&A box on your control panel to type your question. Finally, we'll be using an interactive tool called Kahoot during today's webinar to ask you knowledge-based questions and collect your answers in real time. So let's talk about connecting to Kahoot. If you have a mobile phone or tablet nearby, that's often the easiest and best method to use. You can also use whatever device you're using right now. You'll just need to open another window or tab on your browser. To connect, open your browser and type kahoot.it, then enter today's game pin, which can be found in the Zoom chat and on screen. And I'm gonna give everyone about 15 seconds to go ahead and connect to Kahoot. Okay, do be sure to join us for our next, on October 8th, 2024, for the next installment of the hands-on webinar series. And you can click the link in your chat box to register for that one. Now, I'd like to introduce the panelists for today's webinar. First, Dr. Elizabeth Beverley is a professor in the Department of Primary Care at the Ohio University Heritage College of Osteopathic Medicine and co-director of the Ohio University Diabetes Institute. She's the recipient of the Osteopathic Heritage Foundation Ralph S. Licklider DO Endowed Professorship in Behavioral Diabetes. Dr. Beverley graduated from the Pennsylvania State University with a Doctor of Philosophy degree in Biobehavioral Health in 2008. She completed a five-year postdoctoral fellowship in diabetes at Harvard Medical School with the Joslin Diabetes Center in 2013. And Dr. Beverley's research in diabetes focuses on understanding the linkages among psychosocial issues, self-care, and health outcomes. She employs mixed methodology to examine the culture and context of diabetes self-management in rural Appalachian, Ohio. And Dr. Dan Tilden is an assistant professor at the University of Kansas Medical Center in the Division of Endocrinology, Diabetes, and Clinical Pharmacology. Dr. Tilden is currently a K-12 scholar on the DiabDocs National K-12 Program. His unique background is a former high school science teacher, as well as subspecialty training in both pediatric and adult endocrinology have shaped his research focuses on developing and implementing interventions to improve outcomes for adolescents and young adults with type 1 diabetes living in rural areas. So at this time, I will let our panelists introduce themselves and state their disclosures. I'm Liz Beverley, and I have no disclosures. And I'm Dan Tilden, and I also have no disclosures. Sorry about that. Oh, go ahead, Liz. Thank you so much, Dr. Hilliard, for a wonderful introduction. Thank you to the ADA for inviting me to present on a topic that I'm very passionate about. I am someone, I was actually born in a very rural area. If anyone is from Iowa, I was born in Cebula, Iowa, which is actually a very, very tiny rural area of a population less than 500 people. So I'm very passionate about rural populations, and I've been fortunate in my career to move to different places. So I've experienced major metropolitan areas, small cities, and I've now moved back to a rural area, and I'm devoting the rest of my career to focusing on diabetes care and behavioral health in a rural area. So the objectives today for that I'm going to talk about is I'm going to discuss some of the disparities in diabetes and behavioral health in rural populations. I'm going to talk about social drivers of health and how they influence diabetes and behavioral health outcomes in rural populations. And then I want you to be able to list a minimum of two strategies that can be designed to improve behavioral health in rural communities after listening to this talk. But first, let's dive into the topic of diabetes. So let's do a Kahoot quiz. So the question is, diabetes mortality rates have decreased in rural areas over the last two decades. True or false? All right. And the answer is false. So I'm going to show you some information to give you information as to how I got to that answer. So rural America, the Census Bureau actually defines rural areas as areas outside of urban areas. So it's kind of interesting that that's how we define rural areas. The Census Bureau also defines rural areas as areas that are not heavily populated. So another way to look at it is urban areas are areas that have 50,000 people or more. Now, when I think about the United States, I think about land coverage. And rural areas actually cover 97% of the United States. States that have the largest rural populations are in Ohio, where I'm located, Pennsylvania, North Carolina, Texas, and Vermont. And Vermont actually has about 65% of its population living in rural areas. What's interesting is that 97% of the United States is rural, but only 20% of Americans are living in rural areas. So about 66 million people. Now, conversely, you have urban areas where you have about 3% of U.S. land, but it's home to 80% of the U.S. population. So talking about some diabetes disparities. So diabetes rates are higher in rural areas. And there's a range, it depends on what rural location that you're looking at. But on average, you can say about 17% higher in rural areas compared to urban areas. And they have the highest overall diabetes mortality rates. So getting to that question that we just took a quiz on, over the past two decades, diabetes mortality rates have remained unchanged in rural areas. But they have decreased in suburban and urban areas. So what do we know? Well, some of the newer things have shown that diabetes mortality rates have increased among men in rural areas. And we also know that diabetes mortality rates are increasing in the 25 to 54 year age group. So we are showing some trends of increasing mortality rates, which is why we should really pay attention to this population. Now, when we're talking about behavioral health disparities, behavioral health concerns are prevalent in both rural and urban areas. So this is something that it's not one area having more issues than another. So this is just some data. This is a little bit older data, but this is looking at statistics across the United States, looking at large metro, small metro, semi-rural, and rural. And you can see here that looking at major depression and other serious mental illness, you can see across the board that we have high prevalence rates of major depression, and we have high serious mental illness in all locations across the United States. But there is one thing that does make rural areas distinct, and there is a specific disparity, and that is with suicide rates. So suicide rates are higher in rural areas than urban areas. You can look at this, and this is data that was released in 2024. You can see here there are rates are much higher in rural areas. And if we look a little bit deeper into that data, you can see here that specifically for men, rural suicide rates have increased 34% in the last 10 years. And for women, in the last about 20 years, suicide rates have doubled from 2000 to 2018. And it's just important to note also that you can see a pattern that in both rural and urban areas, suicide rates are higher for men. So what's going on? Well, there's a lot of things going on, and a lot of it has to do with these social drivers of health, or another way to think of it is social determinants of health. So there are a lot of things that happen in rural areas that can be explaining some of these disparities. So economically, the average income is lower. There are fewer employment opportunities. In terms of education, the average educational attainment is lower in rural areas, and there is lower health literacy. In terms of the environment, there are much more transportation barriers. Most rural areas do not have a public transportation system, and a lot of times there are roads that are not paved. There are windy roads that are very narrow. And for example, where I live, which is part of the foothills of the Appalachian Mountains, you know, these are very windy roads that are part of the mountains. So it's very difficult sometimes to travel on these roads. The environmental context as well is that there are increased rates of substandard housing. There are lower rates of sanitation and water facilities. There's decreased access to fresh and healthy foods, which is really important, particularly not only for mental health and behavioral health, but also for diabetes, because we know that there's an association with access to fresh food and healthy food, and its association with diabetes as well as with the gut microbiome and its association with inflammation, which can lead to depression and other psychosocial outcomes. In terms of healthcare, rates of uninsured are much higher in rural areas. There are fewer hospitals and emergency departments. There are fewer diabetes specialists in terms of endocrinologists and diabetologists, and there are fewer behavioral health specialists. And socially, there's been a lot, I would say, since the COVID-19 pandemic focused on loneliness. Social isolation in rural areas is a significant issue. There's also a lot of stigma towards diabetes in rural areas, as well as mental health stigma. So along those things, I did mention that there are fewer hospitals and fewer emergency departments. So access to care is a significant issue. So I just wanted to highlight a few points. Overall, about 10% of practicing physicians are in rural counties. And in 2023, 65% of rural counties in the United States had a shortage of primary care physicians. Another interesting fact is that only 1% of residency programs are located in rural communities. And 65% of rural counties do not have a psychiatrist. And 81% of rural counties do not have a psychiatric nurse practitioner. And we know the importance of having a psychiatrist or a psychiatric nurse practitioner for managing behavioral health outcomes. And then, of course, looking at diabetes self-management education and support, 62% of rural counties do not have diabetes self-management and support programs or certified diabetes care and education specialists. But that doesn't mean that there is no hope. There are excellent programs out there. And what I wanted to do is highlight some of these very effective programs that have been published in the literature and show that there are programs out there that are scalable that you can take to your community. So here are three wonderful trials that I wanted to highlight. There's PROGRAM-ACTIVE, there's the COMRIDE trial, and the LIVING HEALTHY trial. So with the PROGRAM-ACTIVE design, it's a multi-center randomized control trial. It was conducted in Ohio, actually the part of Ohio where I'm located, but I didn't have anything to do with it. So in Ohio, West Virginia, and Indiana. So the portions that were in Indiana were more urban, but this included rural sites as well as urban sites. It included adults who had type 2 diabetes for at least a year, who met criteria for major depression from a clinical interview. And they were randomized one-to-one for four groups. And these were the four different groups. There was the cognitive behavioral therapy group, and they had 10 sessions over 12 weeks. There was the community-based exercise group where they had 12 weeks of exercise, and six of those were with a personal trainer. There was the CBT, the cognitive behavioral group, which I'm going to be using as CBT, with exercise, and it was concurrent over a 12-week period. And these were all compared to usual care. And the primary outcome for this randomized control trial was depression remission rate and change in A1c. So looking at some of the results post-intervention, you can see the full remission for major depression. The CBT arm was 66%, the exercise arm was 72%, and the CBT plus exercise arm was 71%. So comparing these to usual care, the full remission for major depression in these was five to six times greater in either the cognitive behavioral arm, the exercise arm, or the combined arm. So very successful intervention. Now, when looking at change in A1c, only the cognitive behavioral therapy plus exercise arm showed a significant change in A1c compared to usual care. And then I also wanted to point out that they also looked at other behavioral health outcomes. So the cognitive behavioral therapy arm, the exercise arm, and then the combination arm also showed improvements in diabetes distress. And then the exercise arm and the cognitive behavioral arm showed improvements in quality of life. Now another trial, which was the COMRAD trial, and this trial was a 12-month randomized control trial comparing CBT and lifestyle counseling to usual care. And this trial was conducted in North Carolina, and this had 139 adults with type 2 diabetes. The A1c had to be greater than 7%. And with this, they had to have a positive screen for diabetes distress or depressive symptoms. For those, they used the short questions. And if there was a positive screen, they were included. At enrollment, what they did is they did the full screen for the PHQ-9 and the diabetes distress 17. And based on those scores, they were assigned to one of the two interventions. And what's really interesting about this is this was a trial that was implemented in an active, busy primary care office to be integrated care. So you had lifestyle counseling if your PHQ-9 score was less than 10, or your diabetes distress scale was less than 2. And you were put in the CBT arm if your PHQ score was 10 or greater, or your diabetes distress score was 2 or greater. And so what they did is they had a severity staged randomized control trial. Because a lot of times when you have real-life situations, people are going to have a differing severity of scores in terms of depressive symptoms or diabetes distress symptoms. And so that's how this integrated care randomized control trial approached the issue. Now, all participants in this randomized control trial received 12 individual behavioral health sessions in the first six months. And then they had their subgroup interventions. And what they did at six months is they did a reassessment. And at the reassessment, they adjusted the intervention. So let me get to some of the results. There was a trend towards greater reduction in A1C in the intervention group comparing to usual care. So you can see in the intervention group, and again, the intervention group included the lifestyle group and the CBT group all combined. And you can see here the reduction is nearly a full percent in A1C. And looking at some of the behavioral health outcomes, you can see that it decreased regimen-related distress, it decreased depressive symptoms, it improved self-care behaviors, and it improved medication-taking behaviors. And the last trial that I really wanted to highlight is a cluster randomized control trial that was in rural Alabama. And what was unique about this trial is that participants were community-dwelling adults, and they reported chronic joint pain. Importantly, you had to be willing to participate in a walking program. And so this was focused on individuals with type 2 diabetes who had chronic pain, and it was to get them to become more active in terms of walking. And so for this analysis specifically, I'm going to present the data that they had on some of the behavioral health outcomes. They do have other papers where they presented information specifically in terms of pain and some of the glycemic outcomes. So they had a total of 177 participants who were matched with a peer coach. So a lot of times in rural areas, if we have access issues with providers and not enough behavioral health specialists, peer coaching or community health workers or patient navigators might be an ideal way to approach this. And so this was a really great trial because they used a peer coach approach. And so they had eight telephone sessions for three months for the Living Healthy Program, and that was the intervention arm, or you were assigned to the attention control, which was a general health program. And the general health program addressed general health things such as cancer, driving safety, osteoporosis, and other general health things that would be beneficial to any population participating in the program. And it's important to note that the peer coaches that they had had been a part of previous diabetes studies. So all the peer coaches had two years of experience in diabetes, and they'd also received training and motivational interviewing. And the peer coaches themselves either had diabetes or a family member with diabetes. So they were very experienced. And so you can see here that the Living Healthy Program integrated cognitive behavioral therapy principles, specifically cognitive restructuring, behavioral activation, and adaptive coping skills. And one of the things that they really focused on was overcoming pain as a barrier to exercise. And what were some of their results? Well, their three-month outcomes showed that those in the intervention reported a greater decrease in depressive symptom scores compared to the control participants. And they also reported a greater decrease in perceived stress scores compared to the control participants. And then when you're looking at the 12-month outcomes, the intervention participants, you still saw a decrease in depressive scores compared to control. And then there was a trend for the decrease of perceived stress at 12 months compared to the control. And I wanted to highlight a really another interesting thing from the Living Healthy Trial. So one of the things that they were focused on was stress reduction, which is really, really important for people with diabetes. And so they were focusing on positive activities. And so you can see here, they were promoting deep breathing, yoga, praying, exercise, and listening to music. So you can see at baseline, you can see the control and intervention and how frequently individuals participated in these activities. At three months, you can see the increase, particularly with the intervention group. And then you can see how many people sustain those behaviors at 12 months. And you can see there was a significant increase in people participating in these healthy behaviors. So what are my key takeaways from this? Well, clearly, these trials focused on cognitive behavioral therapy, and it addressed a range of psychosocial concerns. So we talked about major depression and depressive symptoms, diabetes, distress, and perceived stress. One of the things that I highlighted here, which was really important, was that integrated care trial that came out of East Carolina, that CBT can be integrated into primary care settings. And you can involve healthcare professionals as well as behavioral health providers. And then the trial that came out of Alabama is that you can use peer health coaches. CBT can be tailored to individuals to meet their unique needs. And you can have a severity tailored approach based off of how severe someone's depressive symptoms are or their diabetes distress symptoms. And then I also really wanted to focus that these trials really put an emphasis on exercise. And you could see from two of the trials, the benefits of including exercise in terms of reduction of depressive symptoms and diabetes distress symptoms, as well as showing improvements in glycemic outcomes. So what are some key considerations for you to think about? Well, rural areas still have all those social drivers of health to work on. So if there are ways for us to really focus on physical infrastructure and addressing these socioeconomic barriers, those are things that are critical because that's where we're going to need to improve health outcomes in rural areas. We really need to expand residencies in rural areas so that there are more physicians willing to practice in rural counties. We should also increase behavioral health internships in rural areas so that more behavioral health providers want to work in a rural area so we can address some of these healthcare access gaps. And I just wanted to emphasize that these were three different trials from three different areas across the country that show the effectiveness of different approaches for targeted behavioral interventions in rural areas. So looking at these can show that they're evidence-based and we can take these programs and scale them and use them to be sustained in rural areas. And this is how we're going to use this for population health improvements. And I just wanted to thank you again for the opportunity to be here and to share some of this information. And what I'm going to do next is I'm going to be turning this over to Dr. Daniel Tilden to hear about his information in rural areas focusing on type 1. Thank you. Awesome. Well, thank you so much, Dr. Beverley. I really appreciate that. So good afternoon. I'm Dan Tilden. And let me, I'm getting control of the screen. There we go. We're going to first start before I do my part and do a final question about Dr. Beverley's content. So the active, program active 2 study showed that only CBT and exercise intervention significantly improved hemoglobin A1C levels. So 10 more seconds to answer true or false. Great. So true keyword there is only, I'm like I said, I'm a former teacher. So, you know, you got to pay attention to those questions. So great. So again, I'm Dan Tilden. I'm an assistant professor at the University of Kansas Medical Center in the division of endocrinology, diabetes, and clinical pharmacology. And I'm really excited to be able to talk to everyone today about an area I'm really passionate about, specialty care access for adolescents and young adults with diabetes in rural areas. Before we dive into that, you have to answer another question. So which aspect of type 1 diabetes care did primary care providers express the least confidence in? So where do you think primary care providers are the least confident in their care of these patients? Good. Awesome. Yeah. So, treatment with bumps. Some of you can leave already, but no, please don't. You already got the answer right. So good job. And we'll talk more about that. So I wanted to first say that I really appreciate Dr. Beverley for setting up my part of the discussion today, and thank both Dr. Hilliard and the ADA for the invitation to present. So with my time, I want to hone in on the pediatric and young adult population with diabetes, and in particular those with type 1 diabetes, and focus on what we know and don't know about how best to address the needs of this population. To give a bit of a spoiler, the answer is that while there are some really amazing programs and work that's ongoing, we don't really know enough about how best to serve this population. But with that being said, I do think there are some important ways that we can use what we already know about what excellent care in young adults in urban populations and what works with adults with type 2 diabetes and other chronic diseases to give us a sense of what the path forward should look like to build equitable and sustainable care models for this population. So first to kick things off, we'll start, we'll talk a little bit about the importance of diabetes technology and psychosocial care. Then we'll move on to talk specifically about patient perspectives and then evidence regarding specialty care options in the current state, and then novel interventions in future directions of where I think that we should go as we move forward to address these care gaps. So while this isn't likely new to this audience, but I did want to review that people with type 1 diabetes in general are at high risk for adverse psychosocial outcomes, and adolescents and young adults in particular carry a markedly elevated risk for somewhere between one in five and one in two youth with type 1 diabetes, excuse me, reporting mental health challenges with more than half experiencing significant diabetes distress. This fact is reflected in society guidelines that recommend not only screening, but also integrated behavioral healthcare services to help address the needs of this population. And I think that's really important as a practitioner, the integrated aspect of this, because the goal ultimately is to improve outcomes for this population. And that is best achieved when someone like myself, a diabetes practitioner, is working together hand in hand with a psychosocial provider to optimize outcomes and identify the ways that we're going to best approach the care for this patient. So another piece of type 1 diabetes care that's really key to emphasize is the role of technology in improving glycemic and psychosocial outcomes in both pediatric and young adult populations with type 1 diabetes. So data from the top panel are from the CITI trial of about 150 adolescents, which showed that just simply giving these patients continuous glucose monitors compared to their, compared to finger stick blood sugars, improved diabetes outcomes. In the bottom panel there are results from one of the new automated insulin delivery systems, which integrate continuous glucose monitors with insulin pumps to allow for delivery of automatic boluses that also resulted in significant reductions in hemoglobin A1C compared to standard of care insulin delivery. And so it's really, so both of those, these things highlight that optimal glycemic care requires access to at least continuous glucose monitors with mounting evidence that most, if not all patients with type 1 diabetes should also likely be on these AID systems. While there've been concerns about the impacts of diabetes technology generally and CGM use specifically on psychosocial outcomes, the large studies that have been done have shown a net result that CGMs tend to actually to improve quality of life for most patients with type 1 diabetes. And while this certainly isn't universally true for all patients, the significant reduction in the burdensome self-care management tasks and predictive low alarms likely both lead to these improvement in psychosocial outcomes as highlighted by the data here. And together these data have pushed the ADA and among other groups to the state that really continuous glucose monitors, as I said before, are the standard of care for patients with type 1 diabetes. So while clinical, well, this clinical trial evidence and guidelines are clear about the benefit of CGM, access is not universal. And that's likely due to multiple factors, including the needed training for these devices, insurance barriers, and the lack of consistent access to broadband internet and compatible cellular phones. And similarly, while data are clear that whole person diabetes care is critical and that addressing psychosocial needs is a really important part of not only improving quality of life, but also that distress and depressive symptoms are frequent barriers to optimal diabetes care, especially in adolescents and young adults. And so improving access to both of these are really important. And so hopefully that's laid a little bit of the groundwork for our discussion. So let's move on now to talk specifically about the barriers that are experienced by adolescents and young adults with diabetes living in rural areas. So the first critical time period for support is immediately after the diagnosis of diabetes. In multiple qualitative studies of newly diagnosed rural families, there are a number of recurring themes regarding access to diabetes care, navigating care systems, and obtaining diabetes technology. First, and particularly when diabetes is diagnosed at rural hospitals, if access to diabetes education is not timely, this can lead to delays in care or even in readmission as highlighted in the first two bullets. When understandably anxious parents lack appropriate support to interpret a flood of new blood sugar data, the results can be easily overwhelming. Second, even after initial diagnosis, the highly specialized nature of type 1 diabetes care often leaves parents and patients and families to learn about and advocate for optimal diabetes care as primary care providers are not always familiar with new innovations in care. In similar work done by the group from Wayne State University in the upper peninsula of Michigan and our group here at KU, we've found that young adults identify significant barriers to specialty access, including CDCES and psychosocial care, mirroring the experience of newly diagnosed patients. Similarly, our young adults in Kansas highlighted the lack of connection that young adults feel between themselves and the often rotating group of providers who staff outreach clinics at our more remote areas. One of our research subjects in the final quotation here sharply highlighted the bind that rural adolescents and young adults find themselves in. On the one hand, they can see a local PCP who is more easily accessible, but who may lack needed subspecialty expertise, or they can see more distant, less easily accessible specialty providers who may be better equipped to address their specific diabetes and psychosocial needs, but require additional resources from patients, such as time off and transportation access, as highlighted by Dr. Beverly in her talk. So with a bit more context of the patient experience, I wanted to next zoom out a little bit and talk more about what care access looks like in adolescents and young adults across the nation, and then use my home state of Kansas as an example to explore the options for access for these patients. So distance and rurality, again, as Dr. Beverly highlighted, is a significant issue. In this study using data from 2012, more than a third of the pediatric population lives more than 20 miles from an endocrinologist. You can see that with providers focused in large metropolitan areas, those who live outside of those population centers will need to travel significant distances to access the additional supports provided by these subspecialty care clinics. And for some, these are barriers that can be overcome, but for other patients, it likely results in them choosing other avenues for care. To put an even finer point on this, if we focus specifically on my home state of Kansas, patients living in the western half of the state face at least two-hour drives to come to even the closest provider. So I actually have a rural outreach clinic here in Thomas County in Colby, Kansas, which the drive to me here in Kansas City is more than four hours. And their nearest diabetes provider is at least three hours in Salina. And if you're looking for a pediatric care provider, you need to go at least three and a half hours to Wichita or to Topeka. So these are really significant distances that impose significant burdens on these patients. And it is understandable from that perspective then that patients often choose to seek care from their primary care providers. And while rural primary care providers are a huge resource in their communities and are some of the most important people to the health of rural cities and towns, they realistically can't be everything to everyone. This is a survey-based study which asked primary care providers to reflect on their confidence in various aspects of diabetes care and patient advocacy. And you can see that diabetes technology and providing psychosocial care are among the areas where PCPs have the least confidence in their ability to support patients with type 1 diabetes. This certainly is not to say that these patients are ill-equipped or not doing their jobs well, but simply to highlight that these providers are stretched very thin and that these areas, diabetes technology and psychosocial support, while they're critical for patients, rural providers need additional support to ensure optimal care for this patient population. So to summarize, while seeking care from a rural primary care provider may have a number of advantages, needs of access, local knowledge, et cetera, there are significant areas, including technology access and psychosocial care, that have been identified by patients and providers themselves as areas of need. On the other hand, the other option for patients is traveling for subspecialist care, which also has potential benefits and challenges. While on first blush it seems like this might address some of the most significant challenges that we've highlighted, compared to PCP-based diabetes care, traveling for care or seeking care at a more distant site means patients and caregivers will need significant time off, must pay for transportation, and often incur other expenses outside of the increased expense and cost associated with the diabetes care itself. And furthermore, it turns out that several lines of evidence suggest that patients coming to large urban centers from rural areas don't actually even receive optimal care. So in this study from the University of Washington of 61 patients who were cared for at their pediatric diabetes clinic, you can see that there are significant differences in the visit frequency, adherence to regular appointment schedules, excuse me, and importantly, inpatient admissions when comparing urban patients to those coming to the clinic from a rural area. Similarly, in our recent work, we found significant differences among those from the most rural settings in the use of CGMs. And this is despite all of these patients being seen in urban-based pediatric care center or rural outreach clinics that are all staffed by the same group of pediatric endocrinologists. So these data suggest that while our urban-based centers might have the resources to provide optimal diabetes care, rural patients still experience disparities in the care that they actually receive. And overall, this leaves these patients in a bit of a pickle, right? So if your local PCP isn't confident or equipped with the resources for the care to provide you with the diabetes care that you need, and traveling up to four hours to an urban center is still leaving you lagging behind your urban peers, it's really hard to figure out how our current systems of care can allow patients to get access to the care that they need, which is why I think that from my perspective, these data leave me thinking that we need to think outside the box, right? That we need to, in order to address these care gaps that these patients are experiencing, we need to think about novel approaches to care. And so I wanted to highlight a couple of those today. The first and probably the most obvious is telehealth. So telehealth, even before the COVID-19 pandemic, has been studied among patients with type 2 diabetes with very promising results. And the group from the University of Nebraska in particular has done some really nice work to show that the way that they've been able to improve outcomes among patients with type 1 diabetes living in rural areas through facilitated telehealth to local partner clinics where they have a nurse that's associated with the clinic who goes to rural clinics and facilitates the telehealth care that is being done by an urban-based provider. Another particularly well-studied and effective telehealth model for adolescents and young adults in particular with type 1 diabetes is the Colorado Young Adults with Type 1 Diabetes or with T1D or Coyote Care Model. So this model incorporates telehealth diabetes care visits along with virtual peer groups that have shown significant improvements in glycemic and psychosocial outcomes, as well as remarkably high visit attendance among patients with type 1 diabetes in this very high-risk population. While the patients included in the Coyote Clinic are not necessarily rural, their telehealth-based visit model provides a potential path forward for future testing in a rural setting and notably has a patient population that mirrors a lot of the sociodemographic disparities that we observe in patients in rural settings. Another novel approach is the echodiabetes model. So echodiabetes is built on the ECHO model from the University of New Mexico and was adapted for use in insulin-requiring diabetes by a team of researchers at Stanford and the University of Florida. I assume that most people on this call probably are familiar at least to some degree with ECHO, which is a telementoring model where a centralized multidisciplinary team of diabetes experts including physicians, dieticians, educators, and behavioral health specialists mentor a group of interested PCPs who participate in didactic sessions and case presentations to solicit feedback about their care management decisions and gain additional skills, which they then use to go back out to their patients with diabetes to improve their care. Importantly, the central specialty team plays only an advisory role and doesn't directly interact with the patients with type 1 diabetes and only advises their providers, allowing for scalability of the model. Results from the echodiabetes model have been highly promising, with PCPs increasing their confidence in providing excellent type 1 diabetes care. And further iterations of the program have added local diabetes support coaches, which act as community health workers, again, like Dr. Beverly highlighted. And these are people actually who typically have type 1 diabetes themselves, who serve as clinic-based mentors to help patients navigate their care and specifically to help them address psychosocial barriers they experience along their diabetes journey. And while final results of the echodiabetes program are still pending, this work I think represents one promising new pathway for addressing the needs of rural individuals. So finally, I wanted to talk a little bit about future directions. And to start, I wanted to sort of circle back to some of the location-based data that I highlighted earlier. Well, again, ECHO was developed in California and Florida. And even though that map is a lot smaller now, hopefully you can see that, you know, there are certainly are areas of both of those states that are quite distant from central urban areas. But the population and the sort of disparities and ability to access that care is quite different in Florida and California than it is in a state like Kansas. So in the bottom right panel is a map of Kansas. Again, you guys are becoming experts in Kansas geography as well. And so each of the 105 counties in the state is pictured there. The counties that have a number inside them, that number represents the number of actively practicing primary care physicians in each of those counties. So those that don't have a number have more than two. But those that are green have either two actively practicing PCPs or one. And those that are highlighted in red actually have zero actively practicing primary care providers. And so while ECHO Diabetes might be a really great program in those areas that have good PCP coverage, expanding with a lack of PCP availability and an expanding number of ECHO programs, relying primarily on PCPs to deliver type 1 diabetes care for a small number of patients is likely isn't a solution that is going to serve sort of isn't going to be a one size fits all solution for all rural patients living with type 1 diabetes. And so I think that's where some future directions and new technology are really going to be the pathway forward. So first, while mobile health applications aren't going to completely address barriers to care, I think capitalizing on the high number of young adults who, even if they live in rural areas, are still digital natives. And it's one of the important potential avenues that we have to advance care in the future. And these interventions can augment care, not serve as a replacement, but augment care and help us to identify those at high risk for acute complications who may benefit from more targeted interventions. And last, I wanted to highlight the collaborative care model. So in this model, a remote subspecialist provider works in collaboration with rural primary care providers, as well as patients, to augment local resources through telemedicine based multidisciplinary specialty care. This model started to improve access to mental health care, but also has been studied in adults with type 2 diabetes and co-occurring depression, and recently has been expanded outside of mental health care to address palliative care needs among those with heart failure and COPD. And to me, this is the sort of creative model that leverages the strengths of local PCPs and empowers patients and rural providers to be members of the diabetes care team, and is an exciting pathway forward towards improving access to diabetes care, even in the most remote areas. So while we certainly have a long way to go, new technology and care models provide me with hope that we're on the right track to improve access to psychosocial care for young adults living with type 1 diabetes in rural areas. And so now your last Kahoot question. So echodiabetes provides direct patient care interactions between specialist care providers and patients. So hopefully, if I didn't go too fast. All right, it is false indeed, yes. All right, good. Okay, thank you, Dr. Tilden and Dr. Beverly. Those were really great talks and I hope people will put their comments and their questions in the Q&A. But while you're doing that, take a look at these five hands-on takeaways from today's panel and I'll give you a minute to review them. Okay, so I'd like to thank our two speakers for this wonderful presentation today. If you haven't already, like I said, please ask your questions for the presenters by typing them into the Q&A box on Zoom. And we have some questions already that have come in. So one question, there is a lot of information about physical activity. So what is it about physical activity that improves mental health? What's the dosage and how can healthcare providers engage in conversations with their patients or clients about physical activity? I can start with this and thank you, Michael, for the question. I also think that Michael could answer this since Michael is an exercise physiologist and CDCES. So exercise provides a lot of things in physical activity. First, it releases endorphins, so it makes people feel better right away. It can relieve stress. It also releases serotonin. Some of the other things are it improves sleep. It can help you feel like you have a sense of control over things. For people with diabetes, it can improve glucose levels. It may be very helpful with weight management, which can also improve mood. Some of the other things it can do have to do with if you're doing the program active trial, it was community-based exercise and you were doing it in the community with others and that's a social activity. So just doing exercise with other people and having it be social can be very, very helpful in terms of boosting mood. In terms of dosage, I'm going to stick with what are recommendations and the recommendations are 150 minutes of physical activity at a moderate level if you're able and then vigorous would be 75 minutes and above. Of course, do recommended stretching and strength training twice a week, but we actually have several exercise physiologists that are on this webinar. So feel free to chime in. Thank you. Another question, how well are text messages adopted by adults compared to youth or adults caring for youth in rural areas to support psychosocial outcomes and adherence or engagement in care plans? Maybe Dr. Tilden wants to talk about that one. Yeah, absolutely. So there's more work that's needed here, I think is sort of the big takeaway. We do know there's been some really nice work done by Lindsey Mayberry and her group using text messages and text message-based interventions to improve regimen adherence and psychosocial outcomes among patients with type 2 diabetes. And so we have a lot of work to do to really understand uptake in diverse populations, but I know that they have an ongoing study using their text message intervention for folks with type 1 diabetes and especially young adults who are typically quite difficult to reach, but they've had a lot of success with using that intervention in this sort of young adult population. And I think it sort of speaks to this, you know, this sort of digital native idea that we wanna meet these young adults where they are and use the technology and use the platforms that they're familiar with to help give them the information they need that's gonna help improve outcomes. Thanks. Dr. Beverly, anything to add about older adults? In terms of the text messaging, my knowledge of doing the text message with adults is that it does work in rural populations and people are receptive to it. Yeah. So yes. Thanks, it is becoming sort of pervasive and not so generationally limited anymore, huh? Good, okay. Another question, is there any research to support telehealth visits with diabetes educators? This is currently not covered by Medicare and I think it could be a great asset in rural areas. Yes, I mean, so I don't know about research. It is certainly being done. We have a really robust telehealth program here at KU for obvious reasons, given the geography that you all are now very familiar with. But we have some alternate sources to pay for it. And so the research base to convince, convincing Medicare to do something and the research that you need to show that it actually works sometimes are the same thing and sometimes they're two different things. And so I think certainly it is something that we find quite beneficial and I think our patients and our educators really find to be really fruitful conversations. And so definitely is an area where we need to work. I'll say, even though I'm not one of the speakers, we're actually finishing a study right now where we train diabetes educators to do quality of life interventions with people in different clinical settings, including people in getting care from a primary care provider. So hopefully soon we'll have some data to share with you about how that went over, but so far seems so good. So I agree, that's definitely an area to expand reach that we're interested in as well. Okay, another question, as providers, what are key psychosocial approaches to engaging with young adults? Engaging with our young adults is a difficult task, but is absolutely one that I think is critically important. So I think from my perspective, really some of the most important and promising findings are out of the group, the Jennifer Raymond's group at Children's Hospital of LA. They've done some really nice work and the virtual peer groups that they've done as a part of the Coyote Clinic have been really impressive in the ways that they've been able to not only have high adherence, but also improve psychosocial and glycemic outcomes for that population. So I think this sort of social connection piece is really, really important for that age group. And we know that from people who don't have type 1 diabetes, but I think in particular, there's a sense of isolation around the diagnosis. And so I think providing that connection is something that is really critical to develop, but it sort of has to be, you have to do it right. It can't feel forced. It has to be a little bit more organic. And so hitting the right note can be really difficult and likely is something that varies by center and requires somebody to be a really strong champion for that kind of intervention. Absolutely. I have a, oh, go ahead, Liz. I was just gonna mention, I haven't been running any interventions with young adults, but locally what we've done, our Diabetes Institute, is we hold events for young youth. I would say youth with type 1 in our region. So sometimes there might be only one individual in an entire school system with type 1. And so we just bring together events and bring the children together at the university because the university has all the infrastructure. And then we actually just formed our own small diabetes camp. And we just use the university and the dorm rooms so that all the children can come together from the different counties. So things like that, I think, can be very, very helpful and powerful. Yeah, absolutely. I think there's some community organizations that do some of that work as well. And Michael commented, he's seen outstanding outcomes related to diabetes camps. And so similar taking elements of that environment and translating them perhaps to clinical practice. Have you guys thought about any elements of camp that could translate to clinical practice? I don't know, but I'm all for it. Let's go on camp outs together and let's get on the pontoon boat and pull kids across the lake. That sounds fun. I'll do that as an adult. I have a question for you guys. Appropriately, you guys talked about a lot of the challenges of rural settings. And I was just wondering, I think there might also be some strengths, maybe just because I'm sitting here in an urban jungle, maybe there's some strengths of also living in rural settings. I heard you talk, Dan, about PCPs being community members and Liz, you talked about physical activity. So I'm thinking green space. I was just wondering if there's other sort of positive aspects of rural settings that we might be able to harness for supporting diabetes. Who wants to go first? Go for it, Liz. Okay, so thank you so much for that question, Dr. Hilliard. There are strengths about being in rural regions. The beauty of being in a rural area alone, I'm in rural Appalachia. And one of the things that I would highlight, not only is it geographically distinct, but it's culturally distinct. And so getting to know the culture of the region. So you have the Appalachian cultural values and those values are loyalty and caregiving and generosity. And so there are things that I've been able to see in this community that I don't think I could see in a city where you see people rally behind someone because there's a community member struggling with a health issue. And the entire community will come out for a football game to donate money for that child. And neighboring counties and neighboring high schools will come out to support at every Friday night football game and you don't, I didn't have that when I lived in small cities or you won't see that in a major city. So there are strengths and everyone knows each other and there are things that you can really rely on in a community like that. Thank you. Yeah, I would second everything you said. I mean, I think it's so inspiring when you go out and talk to some of these providers and the work that they do, the intensity of their caring, they wouldn't and couldn't hold the job that they have for 30 and 40 years as these PCPs often do without really caring deeply for their communities. And so I think that is very clear. And so it's, I see what we're, what I'm tasked with is number one, pointing out to people who don't go to rural areas, sort of the challenges that are experienced there. And then number two, really providing, using that to get resources so that we can provide the tools that these folks who they know what is needed. And so it's not so much that I need to come in and tell them what to do. It's that we need to give access to the resources that these providers need to give the care that they know that these patients deserve. And so I think that's one of the benefits and one of the reasons why I'm so inspired by this work is that it's really just, it's more facilitating than it is coming up with some whiz-bang new idea. It's giving these people the tools they need to do the work that they wanna do. Awesome, thank you. And what a great note to end on. So thank you both. Before we end today's session, I wanted to let everyone know what to expect from this point. Later today, you'll receive a post-test by email. So please complete it so you can get your CE credit and be on the lookout for today's webinar recording on the ADA's Institute of Learning page in a few weeks. Remind any fellow ADA members that they can watch this excellent webinar for a one CE credit up until September, 2025. And I wanna say thank you once again to our fabulous panel for sharing their expertise with us today. And I wanna thank each of you in the audience for joining us. And we hope to see you at another ADA webinar in the future. And this concludes the session. So have a great afternoon. Thanks all. Bye.

DiabetesCare

RuralHealth

SocialDeterminants

BehavioralHealth

Telehealth

CognitiveBehavioralTherapy

ContinuousGlucoseMonitors

AdolescentDiabetes

HealthcareAccess

IntegratedCare