Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes

Abstract

Background Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging. Objective To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas. Design Mixed-methods implementation study. Participants 230 patients with clinic-refractory, uncontrolled T2D. Intervention ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period. Main Measures Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c). Key Results From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (− 1.43%, 95% CI: − 1.64, − 1.21; P < .001). Benefits persisted at 12 (− 1.26%, 95% CI: − 1.48, − 1.05; P < .001) and 18 months (− 1.08%, 95% CI − 1.35, − 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years. Conclusions When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07281-8.

Implementation Science Perspectives on Implementing Telemedicine Interventions for Hypertension or Diabetes Management: Scoping Review

“…Timm et al [ 69 ] and Kobe et al [ 70 ] evaluated the implementation process of phone-based interventions. Timm et al [ 69 ] evaluated the fidelity of a phone-delivered health coaching intervention in Sweden to manage or prevent type 2 diabetes among 131 patients in relation to dimensions, enablers, and challenges.…”

“…The authors found that tailoring interventions is necessary and language-skilled facilitators are needed to minimize barriers in intervention delivery [ 69 ]. Kobe et al [ 70 ] examined the implementation of Advanced Comprehensive Diabetes Care, an evidence-based phone call intervention for 230 patients with clinic-refractory, uncontrolled type 2 diabetes. The study found that, when strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully even in rural areas [ 70 ].…”

“…Kobe et al [ 70 ] examined the implementation of Advanced Comprehensive Diabetes Care, an evidence-based phone call intervention for 230 patients with clinic-refractory, uncontrolled type 2 diabetes. The study found that, when strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully even in rural areas [ 70 ]. Steinman et al [ 47 ] evaluated the process of researchers partnering with a nongovernmental organization (MoPoTsyo) to implement a health behavior change voice messaging intervention aimed at improving NCD management for patients living with diabetes or hypertension in Cambodia through interviews with 20 patients and 6 HCPs.…”

“…The intervention characteristics domain focuses on the features of an intervention that might influence implementation [ 44 ]. A total of 60% (21/35) of the studies discussed factors that facilitated the implementation of telemedicine interventions for hypertension or diabetes [ 47 , 49 , 51 , 54 , 59 - 63 , 65 - 67 , 70 - 76 , 79 ]. In total, 29% (2/7) of the web-based studies reported that positive perceptions of externally developed telemedicine innovation, described as gathering external expertise on clinical, operational, and telemedicine areas, as well as adding new resources to support users may influence success of implementation [ 51 , 76 ].…”

“…In total, 29% (2/7) of the web-based studies reported that positive perceptions of externally developed telemedicine innovation, described as gathering external expertise on clinical, operational, and telemedicine areas, as well as adding new resources to support users may influence success of implementation [ 51 , 76 ]. A total of 20% (7/35) of the studies reported that patients perceived convenience, timeliness, and practicality for tracking blood pressure or blood sugar changes to be advantages for implementing telemedicine interventions [ 47 , 51 , 63 , 66 , 70 , 73 , 75 ]. HCPs perceived telemedicine to be more advantageous than regular care if they underwent training sessions for learning the procedures of the intervention [ 63 , 73 ].…”