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Rural Summer Externship | Experience Reflection

One Rural Externship Grant is given out by the NAFP Foundation each year. Below is an experience reflection submitted by our 2021 extern, Amy Soeun. To learn more about the externship, click here.

NAFP Rural Summer Student Externship

Amy Soeun, M2 (Creighton University School of Medicine)

Chronic Diseases and Diabetes

The rise of chronic diseases creates a huge toll on the United States due to its impact on people’s quality of life and the health care system. According to the Centers for Disease Control and Prevention (CDC), chronic diseases are “conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.”4 With an increase of the aging population, the prevalence of chronic diseases has increased, with six in ten adults having a chronic disease, and four in ten adults having two or more chronic diseases.4 Chronic diseases possess a potential risk of developing more serious complications, and having two or more chronic diseases can increase that risk and require more complex care. Due to its long-term impact, chronic diseases require continuous care and management leading to a large impact on health care cost contributing $3.8 trillion annually.4

Diabetes is one of the most challenging chronic diseases today. In 2018, it is estimated that 34.2 million people or 10.5% of the U.S. population have diabetes.5 Out of the 34.2 million people, it is estimated that 7.3 million people are undiagnosed which can lead to more serious health problems and risks.5 Due to factors like physical inactivity, increased age expectancy, and poor diet, the prevalence of diabetes among adults 18 years and older has increased from 9.5% in 1999-2002 to 12.0% in 2013-2016.5 Along with the high prevalence of diabetes, 34.5% of the adult population has prediabetes. Adults with prediabetes are at risk for developing diabetes and potentially more serious complications if they are not monitored and if they do not make changes to reduce their risk of developing diabetes.5 The current prevalence of diabetes and the prevalence of prediabetes raises a concern for a continual rise in diabetes and its impacts on the U.S.

With an increase in prevalence, there is a large health care cost for managing diabetes. The estimated cost in 2017 is $327 billion which is a 26% increase from $245 billion in 2012.1 Hospital inpatient care, diabetes medication and supplies, prescription medication for diabetes-related complications, and office visits all contribute to the direct medical cost for managing diabetes. Indirect cost of diabetes includes increased absenteeism, reduced productivity, inability to work, and loss of productive capacity due to early mortality.1 The complexity of diabetes treatment and management causes the high cost of health care, and the effect of diabetes on individuals enlarges the cost.

With no cure for diabetes, it is a lifelong disease that causes high morbidity and mortality. Diabetes is the seventh leading cause of death, and the majority of the deaths are caused by diabetes-related complications.3 Some complications include heart disease, kidney disease, vision loss, and lower-limb amputations.3 These complications increase the complexity of treatment and management, therefore, continuing to augment in health care cost and morbidity of diabetes.

Rural Disparities

Chronic diseases like diabetes have a large impact on the U.S. as a whole, but disparities exist between rural and urban areas. Rates of chronic diseases including heart disease, diabetes, and hypertension are higher in rural communities than in urban areas.6 The prevalence of diabetes in rural areas is 12% compared to 10.4% in urban areas.8

The disparities present in rural areas are impacted by several factors including an aging population, health-related, environmental factors, healthcare access barriers, and screening rates.6 Health risk factors for diabetes include obesity, hypertension, and high cholesterol, and these are present at higher rates for residents in rural areas.8 Rural residents are also more likely to be physically inactive. Environmental factors in rural communities include less access to healthy foods.8 Physical inactivity and unhealthy eating can increase the risk factors for diabetes and diabetes itself.

Limited access to health care also contributes to the risk of developing diabetes and diabetes-related complications. Only 62% of rural communities have access to diabetes health care and education.8 The scarcity of health care access is impacted several factors. There is a lack of providers, especially specialty care providers, who are necessary to assist with management of individuals with diabetes. There are high rates of uninsured individuals which limits access to primary and preventative care leading to more acute care of diabetes and complications. Less options in transportation further restricts access to health care.8 Due to diabetes prevalence, large cost burden, and health impact, it is important for health care providers and health systems to consider ways to reduce the burden of diabetes especially in rural communities.

Diabetes Self-Management Education

Diabetes Self-Management Education (DSME) is an approach to diabetes management that provides individualized support, education, and care for people with diabetes. DSME is led by diabetes educators who are “health care professionals who have specialized training in diabetes care.”7 DSME is a method to assist in controlling diabetes and reducing diabetes-related complications for patients. Diabetes educators can discuss issues about understanding diabetes and treatment, healthy eating, physical activity, monitoring blood sugar, reducing risk for complications, and coping with emotions related to diabetes.2 Diabetes educators work with providers, nurses, care coordinators, and other health care team members to provide high-quality care for patients with diabetes and reduce health care cost.

Impact of Diabetes Educators

Care for patients with diabetes involves collaboration and coordination between multiple health care professionals. Diabetes educators can be valuable team members in the primary care settings to assist with managing patients with diabetes. Diabetes educators and DSME have proven to lower A1C levels, reduce diabetes complications, and improve quality of life.2

Along with the health benefits of the utilization of diabetes educators, their impact can have benefits in reducing health care cost. It has been found that patients who use diabetic educators are receiving more primary and preventative care causing them to have larger outpatient and pharmacy cost, but in turn, have less acute care and lower inpatient cost.7 These lower costs are present in both Medicare population and commercial population indicating the benefit of a diabetes educator.7 Patients who received diabetes education had higher rates of diabetes monitoring measured by the frequency of receiving recommended tests. Patients who had multiple sessions with a diabetes educator had better adherence to medication than patients with a single or no sessions.7 Incorporation of diabetes educators and the use of DSME has many benefits in primary care settings by focusing on quality care, improved outcomes, and saving costs.


I had the honor to complete an externship with York Medical Clinic, OneHealth Nebraska, and McCook Clinic. Through this experience I gained valuable insight to different models of care including the patient-centered medical home (PCMH) and accountable care organization (ACO). I saw how individual providers, care coordination teams, and larger health organizations manage and treat health conditions like diabetes. This experience demonstrated the value of an interdisciplinary team in health care especially in a primary care setting and how important diabetes educators play in the team for managing patients with diabetes. I hope to take what I have learned from this experience throughout the rest of my training and during my future practice.


1. American Diabetes Association. (2018). Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care.

2. Center for Disease Control and Prevention. (2018, December 18). Managing Diabetes. Retrieved from Center for Disease Control and Prevention:

3. Center for Disease Control and Prevention. (2020, June 11). What is Diabetes? Retrieved from CDC:

4. Center for Disease Control and Prevention. (2021, 28 April). About Chronic Diseases. Retrieved from CDC:

5. Centers for Disease Control and Prevention. (2020). National Diabetes Statistics Report, 2020. Atlanta: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services;.

6. Chronic Disease in Rural America. (2019, November 12). Retrieved from Rural Health Information Hub:

7. Duncan, I., Ahmed, T., Lo, Q., Stetson, B., Ruggiero, L., Burton, K., . . . Fitzner, K. (2011). Assessing the Value of the Diabetes Educator. Sage Journals.

8. University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis. (2020, September 23). Rural Diabetes Prevention and Management

Toolkit. Retrieved from Rural Health Infromation Hub: