Implementation of collaborative goal setting for diabetes in community primary care

Abstract

Collaborative goal setting (CGS) is a cornerstone of diabetes self-management support, but little is known about its feasibility and effectiveness during routine care. The aim of this study was to evaluate the implementation of an existing CGS intervention when integrated by primary care staff. Using a mixed-methods approach guided by the RE-AIM framework, intervention adoption, implementation, reach, and effectiveness were evaluated over 12 months. Three of four sites adopted the CGS intervention, in which 521 patients with type 2 diabetes (9-29 % of those targeted) received CGS. For those with suboptimal glycemic control (A1C ≥ 7.5 %), %A1C decreased by 1.1 for those receiving CGS (n = 204, p < 0.001) compared to 0.4 for a group who did not (n = 41, p = 0.23). Practice characteristics influenced adoption and implementation, while isolation of CGS from the remainder of clinical care likely influenced reach and effectiveness. CGS may benefit patients with diabetes, but a lack of integration by practice staff is a key barrier to overcome during implementation. KeywordsDiabetes mellitus, Self-management, Implementation research, Pragmatic designs BACKGROUND Collaborative goal setting (CGS) between health-care providers and patients has been proposed as a strategy for providing diabetes self-management support in primary care [1,2]. Because of its demonstrated effectiveness in increasing patients' self-efficacy and motivation [3][4][5], CGS has been proposed as a measure of clinical quality [6,7] and is a component of the popular Chronic Care Model [8] and a part of PatientCentered Medical Home (PCMH) certification criteria [9]. However, goal setting and follow-up support activities are seldom reported in primary care [10][11][12] and it is not well understood how CGS can be feasibly, effectively, and sustainably integrated into busy primary care practice settings.Based on formative work in 2010 with Federally Qualified Community Health Centers (FQHCs) across the state of Iowa, we identified a need for means to improve the quality of diabetes self-management

Evaluating the Application of the RE-AIM Planning and Evaluation Framework: An Updated Systematic Review and Exploration of Pragmatic Application

“…The evaluation criteria least frequently reported on in their review were those relating to the use of qualitative methods to understand setting level adoption, as well as the percentage of staff exclusions or reasons why staff were excluded, for adoption, and if and how a program was adapted long term, for maintenance. Measure of primary outcome 40.0% (31,32,36,37,43,44) In one additional article, authors highlighted that this evaluation criteria can be challenging and subjective to report on when there are a variety of important outcomes (38) Measure of primary outcome relative to public health goal 0.0% In one article where a primary outcome was not identified, outcomes were discussed relative to the Institute of Medicine recommendations on physical activity (39) Measure of broader outcomes or use of multiple criteria (e.g., measure of quality of life or potential negative outcome) 40.0% (31,(36)(37)(38)(39)(40) Measure of robustness across subgroups (e.g., moderation analyses) 20.0% (36,39,45) Measure of short-term attrition (%) and differential rates by patient characteristics or treatment group 6.7% (35) One article, that had not reported evaluating effectiveness, reported a measure of short-term attrition (%) and differential rates by patient characteristics or treatment group but reported this under reach (35). Two articles (31,34), one of which had not reported evaluating effectiveness (34), reported a measure of short-term attrition (%) and differential rates by patient characteristics or treatment group, but reported this under adoption (31,34) Two articles reported a measure of short-term attrition (%) and differential rates by patient characteristics or treatment group, but reported in the Methods section (38,43) Use of qualitative methods/data to understand outcomes 20% (32,38,42)…”

“…Ten/Fifteen articles did not report any challenges or benefits of applying RE-AIM (31,32,34,(39)(40)(41)(42)(43)(44)(45). Two/Fifteen articles reported challenges of applying RE-AIM (33,36).…”

Structured education of patient with diabetes: A review of organizational and methodological strategies and success factors

“…simulacijom i postavljanjem obolelih u problemske situacije koje treba da rešavaju. Navedene aktivnosti podstiču uključivanje učesnika u obrazovni proces i pospešuju dugoročnu memoriju [22]. U savremenoj edukaciji, zdravstveni radnik i pacijent postaju ravnopravni, tako da su oboleli u istoj meri odgovorni za uspešno lečenje kao i zdravstveni radnici.…”

“…Kako je u zdravstveno-edukativnom radu cilj trajna promena zdravstvenog ponašanja i implementacija datih saveta u svakodnevni život, predlažu se tehnike aktivnog usvajanja znanja koje podstiču učesnike da (nešto) konkretno rade i da i razmišljaju o tome šta rade. Komunikacione strategije kao što su: postavljanje individualnih i zajedničkih ciljeva u promeni ponašanja, motivacioni intervju, zajedničko definisanje plana praćenja napretka i ostvarenja postavljenih ciljeva, navođenje ličnih iskustava, praktičan pristup rešavanju problema, strategije promene ponašanja i unapređenje samoefikasnosti, omogućavaju dugoročno zadržavanje znanja i podržavaju uspešnost edukacije kod obolelih od dijabetesa [16,18,22]. Johan Hajnrih Pestaloci (Johann Heinrich Pestalozzi), švajcarski pedagog, inicijator reforme obrazovanja i koncepta savremenogobrazovanja, ukazao je na značaj šest koraka u edukaciji.…”

“…Pomoću iskustvenog učenja, fokusom na perspektive pacijenata, oni pretvaraju svoju pasivnu ulogu u aktivno vođstvo, što obezbeđuje relevantno znanje. Samim tim, grupna edukacija pozitivno utiče na psihosocijalno i mentalno zdravlje obolelih [22][23][24].…”