Editor’s Note: The ADCES Awards Program annually recognizes excellence in diabetes care and education and honors members’ service to the Association and the larger diabetes community. Each recipient has a story to tell and practical advice to share.
Being nominated for the 2024 Donna Tomky Excellence in Clinical Practice award was an honor, but being selected was a privilege. Donna was a nurse practitioner whom many of us in the diabetes space admired. I have a passion for diabetes management and offering the latest advancements in diabetes technology to rural Pennsylvania. Being recognized for my work through this award was truly humbling.
I was asked to write about the experience and challenges of being a “one-woman show” in a rural community. I started my career as a registered nurse in numerous capacities at my local rural hospital, where I was asked one day if I would be willing to take over the monthly DSME group classes. That started my career toward advancing my diabetes knowledge by becoming a certified pump trainer and traveling up to 4 hours round trip to attend ADCES PA WPLNG (Western Pennsylvania Local Networking Group) meetings to gain connections with fellow DCESs and industry sponsors.
The fire was lit. My passion for the diabetes space continued to grow, and in 2014, I assisted in setting up a telemedicine service to obtain access to endocrinology for the rural community. The service started as 2 hours a month and expanded to 3 four-hour days a month. With limited resources and transportation issues, I convinced my hospital to expand my reach of DSMES to the community by providing a day per month at 5 primary care professional (PCP) offices (2 of them 25 miles from the hospital) to improve access to diabetes education.
Feeling limited in my ability to help individuals manage their diabetes completely, I returned to school to become a family nurse practitioner. Upon graduation, I convinced my health system to allow me to enhance access to diabetes care from a primary care office. Fast-forward 5 years, I obtained my BC-ADM to practice as a diabetologist, improving glycemic management in a small rural area.
With the limited availability of endocrinology services in rural areas, I focus on self-care management during every visit and integrate education. The incorporation of the ADCES7 Self-Care Behaviors® is discussed at each visit, and shared decision-making tools are established with each person. The individual determines which self-care behavior they want to work on until the next office visit.
I optimize clinical management and technology with every person to determine the best treatment options for optimal glycemic management. My office uses a person-centered approach that meets each person’s needs and desires. Not everyone is receptive to enhanced diabetes technology and should be respected in their decisions. I can allow patients to trial continuous glucose monitoring therapies and insulin delivery devices to determine if they can manage the device before paying for a product they do not like.
Challenges I have faced include figuring out how to address a lack of resources and access to care. I am also sometimes challenged by other practitioners not recognizing me as a specialist in diabetes because I am not an endocrinologist. The controversy from practitioners led me to obtain the BC-ADM certification for the credibility of being board-certified. Providing diabetes management support through the latest technology options is just as crucial for those in rural areas as those in urban areas with access to endocrinology. It is rewarding and satisfying to provide the latest technology options to my patients while optimizing time in range.
Practicing in a rural area, you learn to be creative with care and more open to exploring different ways to meet with patients. Food deserts, limited resources, and a lack of transportation can be barriers that sometimes make for unique patient visits. I perform home visits to those having trouble coming to a physical office. These are some of my favorite visits because you can see a person in their environment, what food sources they have in the home, and if additional resources are needed.
I care for a 35-year-old female who suffered a stroke that left her with cognitive deficits and mobility issues. She was discharged from rehab on a basal/bolus regime, but memory issues would sometimes cause her to forget if she gave her insulin doses, and sometimes, she would omit doses. She was also having difficulty with using a glucometer. At the first visit, we discussed easier delivery methods of insulin and ways to monitor glucose. Libre Pro was applied to obtain trends. Upon download, it was noted that she was having several episodes of hypoglycemia. At that visit, a v-go was applied along with Libre 2. In 1 week, she was experiencing minimal hypoglycemia events and was better able to follow an insulin regime due to ease of v-go use and continuous blood glucose viewing. This was 3 years ago, and she remains consistent with her regime and has maintained excellent glycemic management ever since.
Another patient I care for is a middle-aged gentleman who works as a preacher. When I first started seeing him, his glucose levels were often over 400 on Sundays prior to performing 3 church services, but he would experience hypoglycemia between services. He was not administering insulin as prescribed by his PCP due to labile blood sugars. On the first visit, we discussed and worked on consistency with insulin dosing, but after continuing to notice issues with insulin dosing due to the patient’s fear of hypoglycemia, he agreed to try out an AID pump. Starting the pump assisted with less hypoglycemia, and we utilized activity mode and decrease in carbohydrates for the days he would be preaching or doing physical therapy. His A1C went from 8.5 to 6.4 with minimal fluctuations in glycemic management, and he now has more trust in diabetes devices and still uses the pump to this day.
Living in the community where I practice is a significant plus for me. Going to the grocery store or the local Walmart or eating with my family usually entails meeting a few patients. A small community life is the best for making people feel comfortable to share their issues and concerns with you. Many say they feel heard and not just like a number. Rural health care is not for everyone, but I would not practice elsewhere. Living, practicing, and making a difference in the community in which you live is a fantastic feeling.
Use a person-centered approach and understand the community you are working in—this is especially important in rural areas where resources may be limited.
Where possible, at-home visits can give you a better idea of the environment in which your client lives, which can potentially help better inform their care.
Incorporate the ADCES7 Self-Care Behaviors® into every visit!
Tammie Payne, CRNP, MSN, RN, BC-ADM, CDCES, CPT, FNP-C, is employed at UPMC Everett Primary Care Group, in Everett, PA.
Tammie Payne is on the speaker’s bureau for Sanofi and is a certified pump trainer for Beta Bionics, Omnipod, Tandem, and Medtronic.
The author declares having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
