My Diabetes My Community

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PROJECT SUMMARY Older African Americans with diabetes are a highly vulnerable population. In addition to high susceptibility to external insults such as COVID-19, this population suffers the highest rates of cardiovascular and microvascular complications as well as adverse drug events such as hypoglycemia. To address the unique needs of this population, multiple organizations have called for a personalized approach to setting risk factor goals and self- care plans that account for comorbidities, functional status, and socioeconomic risks. Despite widespread agreement, the clinical impact of this highly personalized approach to geriatric diabetes care has rarely been studied in controlled trials. Interventions designed to personalize diabetes care must overcome multiple challenges to implementation including the brief clinical encounter, lack of engagement between encounters, and lack of systems to leverage community-based self-care resources. We propose to address these knowledge and care gaps by studying the integration of two evidence-based interventions, Managing Diabetes to Gain Opportunities for a More Active Life (My Diabetes GOAL) and CommunityRx. The My Diabetes GOAL intervention is designed to engage older patients in personalized goal setting and chronic disease management. The intervention consists of an initial assessment of health status, hypoglycemia risk, barriers to care, and treatment preferences delivered via the electronic health record (EPIC®) patient portal (MyChart®). A diabetes nurse reviews the survey results with the patient to arrive at personalized diabetes goals and provides monthly telephonic care management. Nurse care management may be significantly enhanced with CommunityRx (CRx), a community resource referral information system, developed in partnership with stakeholders across sectors and local residents. During encounters, a HealtheRx is generated, including resources for basic needs such as food and housing, physical and mental wellness, disease self-management and caregiving. Across the University of Chicago Practice Network, we will conduct a 12-month three-arm parallel pragmatic randomized controlled trial of 600 subjects comparing (1) Usual Care vs. (2) My Diabetes GOAL vs. (3) My Diabetes GOAL + CommunityRx. During the trial, we will (1) evaluate the impact of My Diabetes GOAL Arms versus Usual Care on processes of personalized diabetes care (e.g., decisional conflict regarding goals of diabetes care), (2) evaluate the relative impact of the three study arms on self-efficacy, self-care and utilization of community-based resources and (3) evaluate the relative effect of the three study arms on clinical outcomes (e.g., glycemic control, hypoglycemia, geriatric conditions, functional status) and health care utilization (ED visits and unplanned hospitalizations). We will then conduct a mixed-methods evaluation of the trial experience among key stakeholder groups. Personalizing diabetes care in older African American patients with scalable strategies that acknowledge personal preference, barriers to self-care and community connections have the potential to improve quality of life while avoiding adverse drug events.