Apostle Group Completes "Healthcare to Community" Program

Diabetes is a chronic condition that poses a growing concern across the United States. According to the Centers for Disease Control and Prevention (CDC), nearly 30 million adults are affected by diabetes, with Maryland consistently ranking among the top 25 states for its prevalence. The Maryland Department of Health recognizes the urgency of this issue and is committed to reversing the trend by partnering with hospitals, local health departments, and private healthcare providers across the state.

Apostle Group LLC is proud to have contributed to this initiative by developing a comprehensive four-week "Healthcare to Community" program. This program was supported by an Innovations in Nutrition demonstration grant from the Administration on Community Living, aimed at creating a diabetes care pathway for individuals with type 2 diabetes. The program sought to reduce costs and improve outcomes by connecting healthcare and community-based organizations, such as county Area Agencies on Aging, through eReferrals, while establishing a replicable, billable model for diabetes education and services. It tested person-centered care interventions, including electronic diabetes education, virtual nutrition therapy, online classes, and medically tailored meals. The overall goal was to enhance diabetes self-management, reduce social isolation, and minimize rehospitalizations.

Participants

Participants in the program were either referred by their primary care physicians or enrolled through self-referral. To be eligible, participants needed to be over 60 years old and have a diagnosis of type 2 diabetes. Those at risk of food insecurity could also receive shelf-stable medically tailored meals. The program was offered at no cost to all participants. 

Diabetes Education

Each participant was provided with a tablet that granted virtual access to educational handouts and videos covering a range of diabetes-related topics, including medication management, healthy eating, exercise, and monitoring diabetes complications. The materials were designed to be simple and easy to understand, with large print and clear, concise information. Both written and visual formats were used to cater to various learning styles and help participants effectively grasp the content and apply it to their daily lives. Participants completed pre- and post-quizzes each week to assess their understanding of the topics.

In addition to reviewing the educational materials, participants engaged in virtual one-on-one sessions with Registered Dietitians, which played a critical role in reinforcing the program’s effectiveness. These personalized sessions provided an opportunity for participants to receive medical nutrition therapy (MNT), a key element in managing diabetes. MNT is a proven intervention for improving blood sugar control, supporting healthy eating habits, and addressing individual dietary concerns related to diabetes. During the MNT sessions, the Registered Dietitians also addressed incorrect responses on the quizzes, ensuring that participants gained a clear understanding of the material and any misconceptions were corrected. This immediate feedback helped to reinforce learning and ensure participants were accurately applying the information. Additionally, the dietitians provided tailored guidance and support, adapting their recommendations to each participant's unique health status, lifestyle, and preferences. This personalized approach empowered participants to make informed decisions about their diet and health, fostering better diabetes self-management and ultimately leading to improved health outcomes.

At the conclusion of the four-week program, participants were offered the opportunity to enroll in a six-week virtual Diabetes Self-Management Program (DSMP) provided by Area Agencies on Aging (AAAs). Led by trained lay leaders, the DSMP built on the education provided in the initial program, covering key topics such as understanding diabetes, meal planning, staying physically active, blood sugar monitoring, medication management, problem-solving, reducing the risk of diabetes complications, managing the emotional aspects of diabetes, and improving overall health and quality of life. Research has shown that DSMPs can lead to improved A1C levels and positively impact various aspects of diabetes care. By enhancing diabetes self-management, these programs help reduce complications and lower the risk of diabetes-related hospitalizations.

Medically Tailored Meals

For participants who met the criteria for medically tailored meals, a weekly delivery of shelf-stable meals was provided for four weeks. Each week, participants received a box containing non-perishable food, offering three meals and one snack per day for six days. The boxes also included condiments, utensils, menus, food preparation instructions, and recipes. All ingredients were shelf-stable, requiring no refrigeration, and preparation involved only basic tools such as measuring cups and a microwave or stove.

These medically tailored meals adhered to the nutritional standards set by the Older Americans Act, Title II-C guidelines, and were designed to help manage healthy blood sugar levels. Participants completed a daily survey to assess their satisfaction with the meals, rating both the taste and ease of preparation.

Results

A reproducible diabetes care pathway was developed as part of the program, designed to outline clear, billable steps for care that could be replicated in other settings. This pathway included critical components such as eligibility screenings to identify individuals who could benefit from the program, eReferrals for diabetes education to ensure timely access to resources, and MNT provided by Registered Dietitians to tailor dietary recommendations for each participant's unique needs. Additionally, the pathway incorporated diabetes self-management programs to empower participants with the knowledge and skills needed to better manage their condition, along with medically tailored meals to address nutritional needs and improve health outcomes.

The pathway also made connections to resources aimed at supporting food-insecure individuals, helping to address one of the key social determinants of health that can worsen diabetes outcomes. This holistic approach ensured that participants received comprehensive support to manage their diabetes effectively, both through medical and community-based interventions.

The program demonstrated a positive impact by significantly reducing hospital visits among participants, irrespective of their food security status. This reduction in hospitalizations suggests that the combined interventions—diabetes education, MNT, tailored meals, and social support—helped improve diabetes management and reduce complications. Furthermore, this outcome implies a potential reduction in hospital-related charges, underscoring the program's effectiveness in not only improving health outcomes but also lowering the overall costs associated with diabetes care.

To learn more about how this innovative approach could transform diabetes care and its potential to reduce healthcare costs while improving patient outcomes, we invite you to stay tuned for upcoming articles that explore further details about the program and its impact.