Measuring the Implementation and Effects of a Coordinated Care Model Featuring Diabetes Self-management Education Within Four Patient-Centered Medical Homes

Abstract

Minority individuals experience a disproportionately greater incidence and prevalence of type 2 diabetes. Innovative approaches are needed to reduce health disparities and associated harms among vulnerable populations with diabetes. This thesis examines the effects of the implementation of a coordinated care model with underserved populations in Patient Centered Medical Homes (PCMH) at four sites (Florida, Ohio, Oklahoma, and Tennessee). The model featured diabetes self-management education (DSME) and a patient support intervention delivered within the PCMH context. The components of the comprehensive intervention included DSME, support for managing diabetes and distress, enhanced access and linkage to care, and improvement to quality of care. The primary dependent measures in this study included four clinical health measures-glycosylated hemoglobin (A1C), blood pressure, body mass index, and lipids-and the AADE7 Self-Care Behaviors TM . Coordinated care teams that delivered the intervention included primary care physicians, nurse care coordinators, certified diabetes educators, health behavior coaches, and diabetes patient supporters. Community health workers and medical assistants provided additional individualized support to patients. Care teams provided DSME as well as customized and coordinated patient support within a PCMH setting.This study was part of a larger participatory evaluation of the Bristol-Myers Squibb Foundation's Together on Diabetes initiative. A statistically significant decrease was seen in A1C, the primary clinical health outcome. This decrease was seen across all four implementation sites; ranging from a decrease of 0.4% to 0.9% after 6 months. This improved A1C level was associated with implementation of the DSME and support intervention. Substantial policy and practice changes were also brought about at two of the four PCMH sites. Use of DSME within the PCMH model is a promising strategy for reducing clinical markers for diabetes among vulnerable populations.iv Systems changes, including policy and practice changes, have the potential to have lasting effects within PCMH practice for reducing the burden of diabetes.

Outcomes of a 12-month patient-centred medical home model on patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia.

“…In the secondary outcome analyses, there was a statistically significant difference observed between baseline and follow-up PAM levels where 43% of study patients experienced transition from a lower PAM level to higher PAM level post-intervention. The effect of PCMH care in improving self-management behaviours in patients is consistent across several other studies [37,38].…”

Patient Experience in a Coordinated Care Model Featuring Diabetes Self-management Education Integrated Into the Patient-Centered Medical Home

“…Further, evidence has been presented showing that the delivery of DSME through coordinated care in the patient-centered medical home (PCMH) setting was associated with improvements in A1C and BMI in some contexts and that the PCMH setting fostered sustainability of some elements of the intervention. 15 These results support the notion that compared to a fee-for-service model, provision of DSME in a PCMH may not be as narrowly focused on a given number of hours but instead may allow ongoing provision of education and support. It is recognized that ongoing DSME and diabetes self-management support (DSMS) help persons with diabetes sustain effective self-management even as they face new challenges and as more effective treatment options become available.…”

Lessons From the Community-Centered Health Home Demonstration Project: Patient-Centered Medical Homes Can Improve Health Conditions in Their Surrounding Communities

“…All demonstration clinics had an established social mission, and yet the broadening of their focus from individual patient needs to the community’s needs changed their approach to illness and injury prevention. As documented in previous reports, the PCMH structure increased patient access to secondary prevention and screening services, such as mammograms and blood pressure screening, and to lifestyle and chronic disease self-management education ( 7 , 8 ). The CCHH approach takes this structure a step further by acknowledging that socioeconomic and environmental factors greatly influence behavior and disease risk and that these broader influences must therefore be targeted in tandem with efforts directed toward the individual’s health ( 9 ).…”