Background

About one in four Veterans lives with diabetes. Within the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), diabetes is the leading cause of kidney failure, amputations, and blindness. It is also a major risk factor for heart disease and one of the costliest health conditions for VA.

Good diabetes control can prevent many serious complications and reduce health care costs. However, Veterans who have long-term, poorly controlled diabetes contribute most to VA’s overall diabetes burden. Rural Veterans with type 2 diabetes face special challenges, such as limited access to specialty care and diabetes education. Many rural Veterans continue to have high hemoglobin A1c (HbA1c) levels because they do not have access to effective diabetes care that works well in rural settings.

The VHA Office of Rural Health (ORH) Veterans Rural Health Resource Center–Iowa City (VRHRC IC) created the Advanced Comprehensive Diabetes Care (ACDC) project to improve diabetes care for rural Veterans. ACDC is a telehealth program delivered through VA Remote Patient Monitoring–Home Telehealth (RPM HT) services. It adds structured self-management support and specialist-guided medication management to standard RPM HT telemonitoring.

ACDC is designed to do two main things: lower HbA1c even for Veterans whose diabetes has not responded to usual care, and use existing VA telehealth staff and equipment so that the program is practical to deliver in rural areas. In randomized clinical trials, ACDC significantly improved HbA1c compared with usual clinic care and compared with standard VA RPM HT management.

Goals and Objectives

In Fiscal Year (FY) 2025, the ACDC project team is working with VRHRC IC to support continued growth of ACDC as a Rural Mentored Implementation project. The team will keep delivering ACDC at 27 VHA sites and add 4 more sites.

The Durham VA Medical Center team will review how the program is being used and how well it is working by examining HbA1c trends and other key measures. The specific objectives are:

• Implement ACDC for Veterans with type 2 diabetes who continue to have poor control despite receiving standard VA services.
• Evaluate how ACDC is implemented at each participating site, including successes, challenges, and local adaptations.
• Move mature sites from ORH project funding to ongoing local (site-based) funding while maintaining sustainable ACDC delivery in routine clinical care.

Methodology

With support from VRHRC IC between FY 2017 and FY 2025, more than 1,500 Veterans with type 2 diabetes have received ACDC at 30 VHA sites. Clinical staff deliver the program over six months using standard VA equipment.

ACDC is provided by RPM HT nurses and Clinical Pharmacy Practitioners, who serve as medication managers. The program combines three main elements over regularly scheduled nurse phone calls:

• Telemonitoring: Home telehealth technology collects blood glucose readings and other relevant data. Nurses review this information, reconcile medications, and monitor adherence.
• Self-management support: During most calls, nurses provide structured education modules that help Veterans build skills in diet, activity, medication use, and problem solving.
• Medication management: Based on the information gathered, nurses forward reports and recommendations through the electronic health record to the ACDC medication manager, who adjusts diabetes medications as needed. These changes are documented in the medical record.

The Durham VA Medical Center ACDC team evaluates implementation each year using the RE AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). This helps the team understand how well ACDC is working, how widely it is being used, and how it can be improved and sustained over time.

Impact on Rural Veteran Health

ACDC has shown strong benefits for rural Veterans with difficult-to-control type 2 diabetes.

• ACDC has been proven to lower HbA1c by an average of 1.7 percentage points at six months (from 9.7% to 8.0%) among rural Veterans with long-term poor control, in both research trials and real-world clinic settings. This improvement has been sustained for more than four years.
• Veterans and staff report that ACDC is helpful, acceptable, and easy to work with in daily practice.
• ACDC was selected as a winner of the VA National Shark Tank Competition in 2018, recognizing its innovation and impact.
• Analyses currently under review show that ACDC is cost-saving for VA by reducing complications and the need for more intensive care.

Veteran feedback highlights the value of the program. Veterans often describe ACDC nurses as supportive, responsive, and dedicated to helping them manage their diabetes and related health issues.

Key Takeaways

ACDC offers an effective, scalable approach to improving diabetes outcomes for Veterans—especially those living in rural areas with persistent poor control.

• ACDC reliably lowers HbA1c among Veterans with long-standing, hard-to-control diabetes in both research and routine clinical care. The sustained HbA1c improvements are expected to significantly reduce heart attacks, strokes, and other diabetes complications, which in turn lowers VA’s overall burden of type 2 diabetes costs and health impacts.
• Because ACDC uses existing VA staff and telehealth infrastructure, requires only modest training, and does not require new hiring, any VA site can adopt the program. This makes ACDC well suited for widespread rural implementation across VA.
• The project team has developed an easy-to-use ACDC Program Toolkit to help new sites set up and deliver the program. A detailed ACDC Business Plan supports engagement from local leaders and helps secure ongoing support.
• ACDC meets all six criteria for ORH Rural Mentored Implementation Projects: it increases access to care, builds strong partnerships, demonstrates clear clinical impact, offers a positive return on investment, is operationally feasible, and achieves high customer (Veteran and staff) satisfaction.

Download the Printable PDF for Healthcare Providers and Researchers.

References

• VHA. Close to 25 percent of VA Patients Have Diabetes. (2015).
• Kerr E. A., Krein S. L., Pogach L. M., et al. Diabetes QUERI Strategic Plan. (2011).
• Miller D. R., Safford M. M., Pogach L. M. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. Diabetes Care. 2004;27(S2):B10–B21.
• Yoon J., Scott J. Y., Phibbs C. S., et al. Recent trends in Veterans Affairs chronic condition spending. Population Health Management. 2011;14(6):293–298.
• UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837–853.
• Holman R. R., Paul S. K., Bethel M. A., et al. 10 year follow-up of intensive glucose control in type 2 diabetes. New England Journal of Medicine. 2008;359(15):1577–1589.
• Baxter M., Hudson R., Mahon J., et al. Estimating the impact of better management of glycaemic control in adults with type 1 and type 2 diabetes on the number of clinical complications and the associated financial benefit. Diabetic Medicine. 2016;33(11):1575–1581.
• Lynch C. P., Strom J. L., Egede L. E. Disparities in diabetes self-management and quality of care in rural versus urban Veterans. Journal of Diabetes and its Complications. 2011;25(6):387–392.
• Rutledge S. A., Masalovich S., Blacher R. J., et al. Diabetes Self-Management Education Programs in Nonmetropolitan Counties—United States, 2016. MMWR Surveillance Summaries. 2017;66(10):1–6.
• Crowley M. J., Edelman D., McAndrew A. T., et al. Practical telemedicine for Veterans with persistently poor diabetes control: a randomized pilot trial. Telemedicine and e-Health. 2016;22(5):376–384.
• Crowley M. J., Tarkington P. E., Bosworth H. B., et al. Effect of a comprehensive telehealth intervention vs telemonitoring and care coordination in patients with persistently poor type 2 diabetes control: a randomized clinical trial. JAMA Internal Medicine. 2022;182(9):943–952.
• Glasgow R. E., Vogt T. M., Boles S. M. Evaluating the public health impact of health promotion interventions: the RE AIM framework. American Journal of Public Health. 1999;89(9):1322–1327.

Contact

• Program Contact: Matthew Crowley, Attending Physician, Veterans Rural Health Resource Center–Iowa City, Iowa City VA Health Care System, Iowa City, IA. Matthew.Crowley@va.gov
• Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PROJFY 009527.
• Suggested Citation: Crowley, M. (2025). Advanced Comprehensive Diabetes Care (ACDC). Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.

Rural Health - Navigation

• Office of Rural Health Home page:
  https://www.ruralhealth.va.gov/index.asp
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  https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp
• Veterans Rural Health Resource Centers (VRHRC) page:
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