Engaging Veterans and Family Supporters in PACT to Improve Diabetes Management

背景：患有糖尿病的退伍军人必须控制心血管危险因素，以防止致残 和危及生命的并发症然而，尽管糖尿病护理质量在系统范围内取得了进展， 30%的VHA糖尿病患者持续存在不受控制的血压、高血糖症或 高脂血症全国范围内的VA PACT（患者对齐护理团队）计划旨在提供VA初级 通过全面的、基于团队的支持来护理患者，以遵循糖尿病护理方案。PACT的成功， 然而，这取决于其有效地让病人参与护理的能力。一个相对未开发的资源， 支持参与PACT的是患者的家人和朋友。四分之三的成年糖尿病患者 向无偿的家庭成员或朋友（“健康顾问”）提供持续的糖尿病帮助 管理这些支持者帮助患者坚持服药，跟踪家庭血糖 他们的工作是测量，保持健康的饮食计划，并经常陪同患者进行医疗访问。 然而，虽然PACT强调家庭成员作为护理团队一部分的重要性，但PACT并没有 建立正式机制，让卫生支持者参与PACT护理。健康支持者报告说，为了 为了更有效，他们需要更多有关患者医疗护理计划的信息，以及明确的渠道 与PACT团队成员进行沟通，以及有关导航PACT资源的信息。 结论：这项随机试验的总体目标是测试一种策略，以加强 支持者帮助高危糖尿病患者参与PACT护理并成功制定护理计划。 中心假设是，向健康支持者和 患者将增加患者的活动并改善糖尿病并发症风险的管理。 方法：这将是一项随机对照试验，评估一项干预措施（关爱他人增加 EngageMent in PACT，或CO-IMPACT），旨在组织和促进健康支持者参与 PACT使患者能够更积极地参与PACT护理，并改善他们的糖尿病治疗 过程和结果。220例接受PACT初级护理的糖尿病患者，1）存在以下高风险： 由于高血糖或高血压引起的糖尿病并发症和2）有健康支持者参与 将沿着招募他们的健康支持者。病人和支持者的组合将是 随机分配至CO-IMPACT干预组或常规PACT护理组，治疗高危糖尿病12个月。CO- IMPACT方案提供了患者-支持者二人组：一次关于行动计划的指导会议， 与提供者，导航技能和支持技能;在病人的初级保健访问之前通过电话进行准备; 通过邮件进行访视后总结;以及每两周一次的自动电话呼叫，以提示对新患者采取二联措施 健康问题。CO-IMPACT建立在PACT工具包中集成病历的患者激活工具的基础上 并且被设计为可在现有PACT护士遭遇中实施。本研究的主要结局 包括患者激活有效测量（患者激活测量-13）和5年心脏事件 为糖尿病患者设计的风险评分（UKPDS风险引擎）。次要结果包括患者的自我- 糖尿病自我护理的有效性;糖尿病自我管理行为，包括药物依从性;糖尿病 以及血糖和血压控制。支持者之间的措施将包括支持者 激活、使用有效的支持技术、对患者糖尿病护理的困扰和护理人员负担。我们 还将衡量患者-支持者和患者-提供者关系质量，患者安全（例如， 低血糖症）和利用。我们将测量干预效果的潜在调节因素，例如患者 卫生知识水平，以及参与者和工作人员中更广泛实施的促进因素和障碍。

BACKGROUND: Veterans with diabetes must control cardiovascular risk factors in order to prevent disabling and life-threatening complications. However, despite system wide advances in diabetes quality of care, over 30% of VHA patients with diabetes continue to have uncontrolled blood pressure, hyperglycemia, or hyperlipidemia. The nationwide VA PACT (Patient-Aligned Care Teams) initiative seeks to provide VA primary care patients with comprehensive, team-based support for following diabetes care regimens. PACT's success, however, hinges on its ability to effectively engage patients in care. One relatively untapped resource for supporting engagement in PACT is patients' family and friends. Three out of four adults with diabetes reach out to an unpaid family member or friend (a `health supporter') for ongoing help with diabetes management. These supporters help patients with medication adherence, tracking home glucose measurements, maintaining a healthy eating plan, and often accompany patients to their medical visits. However, while PACT emphasizes the importance of family members as part of the care team, PACT does not have formal mechanisms to involve health supporters in PACT care. Health supporters report that, in order to be more effective, they need more information on patient's medical care plans, clear channels for communicating with PACT team members, and information on navigating PACT resources. OBJECTIVES: The overall objective of this randomized trial is to test a strategy to strengthen the capacity of supporters to help patients with high-risk diabetes engage in PACT care and successfully enact care plans. The central hypothesis is that providing health care engagement tools to both health supporters and patients will increase patient activation and improve management of diabetes complication risks. METHODS: This will be a randomized controlled trial evaluating an intervention (Caring Others Increasing EngageMent in PACT, or CO-IMPACT) designed to structure and facilitate health supporter involvement in PACT so that patients can become more actively engaged in PACT care, and improve their diabetes treatment processes and outcomes. 220 patients with diabetes receiving PACT primary care who 1) are at high risk for diabetes complications due to hyperglycemia OR high blood pressure and 2) have a health supporter involved in their diabetes care will be recruited along with their health supporter. Patient-supporter dyads will be randomized to the CO-IMPACT intervention or usual PACT care for high-risk diabetes, for 12 months. The CO- IMPACT protocol provides patient-supporter dyads: one coaching session on action planning, communicating with providers, navigation skills and support skills; preparation by phone before patients' primary care visits; after-visit summaries by mail; and biweekly automated phone calls to prompt dyad action on new patient health concerns. CO-IMPACT builds on medical record-integrated patient activation tools in the PACT toolkit and is designed to be implementable within existing PACT nurse encounters. Primary outcomes for this study include a validated measure of patient activation (Patient Activation Measure-13) and a cardiac event 5-year risk score designed for patients with diabetes (UKPDS Risk Engine). Secondary outcomes include patients' self- efficacy for diabetes self-care; diabetes self-management behaviors including medication adherence; diabetes distress; and glycemic and blood pressure control. Measures among supporters will include supporter activation, use of effective support techniques, distress about patient's diabetes care, and caregiver burden. We will also measure patient-supporter and patient-provider relationship quality, patient safety (e.g. hypoglycemia), and utilization. We will measure potential moderators of intervention effect, such as patient health literacy level, and facilitators and barriers to wider implementation among participants and staff.