Recipe for Success: Alabama’s Quality Improvement Organization Spreads Community-Based DSME To Ninety-Three Percent of Counties Across State

The CDC reported in 2014 that the rate of diabetes among US adults was 9.0 percent. Alabama’s rate was significantly higher. Alabama had the third highest rate of diabetes in the nation, at 11.1 percent (CDC, 2014). The majority of Alabama is classified as rural or underserved, or both (CDC, 2014). Access to diabetes education was also a problem because only 28 percent of the counties in Alabama had official diabetes self-management education and support (DSMES) programs, and most of these were in urban counties.

Why the concern about rural and underserved communities?

Complication rates are disproportionately higher among racial/ethnic minority groups and persons living in rural areas according to Rural Health Research & Policy Centers, 2011 statistics. Residents of rural counties also face issues with access to healthcare, adequate transportation, low literacy, and socioeconomic issues such as poverty and unemployment (Center for Rural Affairs).

Education Reaps Positive Outcomes

According to the American Association of Diabetes Educators, research shows that people who have received diabetes education are more likely to 1) use primary care and preventive services; 2) take medications as prescribed; 3) control their blood glucose, blood pressure and cholesterol levels; and 4) have lower health costs.

To address the above issues, in August 2014, the Centers for Medicare and Medicaid Services (CMS) directed Quality Innovation Network – Quality Improvement Organizations (QIN-QIOs) to increase access to diabetes self-management education and training in underserved populations nationwide over a five-year period. A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.

The Alabama Quality Assurance Foundation (AQAF), part of Qsource QIN-QIO, set out to increase access to diabetes self-management education by 1) selecting an evidence-based, peer-led curriculum; 2) scanning the environment to identify areas of greatest need and avoid duplication of DSMES services; 3) increasing the number of trained diabetes educators throughout the state; 4) finding community organizations to administer and sustain DSMES programming; 5) marketing workshops in relevant ways to increase awareness; 6) carefully selecting sites to minimize transportation barriers; and 7) assisting current DSMES programs to become American Association of Diabetes Educators (AADE) accredited or American Diabetes Association (ADA) recognized and understand how to correctly bill for DSMES services.

Qsource selected the University of Illinois at Chicago’s Diabetes Empowerment Education Program (DEEP) curriculum which is designed to provide diabetes education in a simple and easy-to-understand format and has proven to be successful for use in low-income, low literacy, and racial and ethnic minority populations. Staff conducted diabetes education throughout Alabama and trained passionate people in targeted communities to properly prepare them to teach community members with diabetes.

AQAF trained 85 educators to teach the DEEP curriculum in their communities. This resulted in one or more diabetes educators for each county. As of June 2019, one or more classes have been taught in 93 percent of the counties (62 of 67 counties), including the counties with the highest diabetes prevalence. Ninety-three percent (51 of 55) of the state’s rural counties have been reached with DSMES through this effort.

AQAF’s success was not achieved alone but with multiple strategic partnerships. A key partner over the past five years was the Alabama Cooperative Extension System who provided the local, accessible workshop sites and community members to train and remain in communities (67 counties). Other partners included senior centers, libraries, local health departments, physician offices, hospitals, housing facilities, universities, and faith-based organizations.

The CMS 5-year contract for this specific diabetes work ends in July 2019, so it is imperative that non-QIO organizations be equipped to continue providing quality DSMES to these underserved populations. Alabama has been successful in assuring three partners are able to do this: Alabama Cooperative Extension System, Innova Primary Care, and North Baldwin Infirmary have each acquired a DEEP license and the latter two organizations have become accredited by the American Association of Diabetes Educators and recognized by the American Diabetes Association, respectively. It is a requirement that positions them to be able to bill Medicare for Diabetes Self-Management Training (DSMT) and is crucial for sustainability.


CDC. Diabetes Report Card, 2014:, accessed 6/17/19.
CDC. National Diabetes Statistics Report, 2017,, accessed 6/17/19.
Pillay, J., et al. Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis. Annals of Internal Medicine 2015, accessed 6/17/19.
Powers, M., Bardsley, J., Cypress, M., Duker, P., Funnell, M., Hess Fischl A., Maryniuk, M.D., et al. Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 2015 Jul; 38(7):1372-1382,, accessed 6/17/19.
American Associationof Diabetes Educators. The Benefits of Diabetes Education webpage,, accessed 6/17/19.
Castillo A, Giachello A, Bates, R, et al. A community-based diabetes education program for Latinos: The Diabetes Empowerment Education Program; Diabetes Educ 2010, 36; 4: 586-594.