A Collaborative Approach to Control Hypertension in Diabetes (COACH-D)

描述（由申请人提供）：许多初级保健患者，特别是在市中心环境中，没有达到血压和血糖控制的目标。迫切需要加强对那些在常规临床护理系统内没有达到目标的人的治疗。我们建议发展一种基于慢性护理模式的多成分干预，并在资源挑战的环境中可持续发展。通过与家庭保健护理的合作，以及使用家庭遥测反馈和强化治疗，我们将增加通常的临床服务，以改善未能达到治疗目标的糖尿病患者的健康结果。有三个具体目标。首先，我们将在我们基于实践的研究网络（NYC RING）的初级保健站点、糖尿病研究和培训中心的临床研究人员以及Montefiore家庭健康组织之间建立一个可行、实用和可持续的合作模式，整合每个合作伙伴的独特专业知识，并确定每个合作伙伴的角色和责任。第二，我们将制定和完善干预措施的组成部分，包括培训初级保健提供者和家庭保健护士，以便将实施干预措施的技术、社会心理和沟通过程结合起来。第三，我们将通过对25名初级保健患者实施干预来评估协作干预的可行性，并通过将结果与25名接受常规护理的患者进行比较，获得初步的有效性估计。我们的建议包括制定可行的数据收集程序的计划，以及评估过程和结果措施的定性和定量方法。我们将利用这些初步数据修订干预措施，并准备R18应用程序，以进一步开发和测试在多个城市内的初级保健站点服务低收入糖尿病患者的干预措施。该建议是针对糖尿病并发症的二级预防，目标人群以健康差异和这种慢性疾病的高负担而闻名。许多初级保健患者，特别是在市中心环境中，没有达到血压和血糖控制的目标。我们建议发展一种基于慢性护理模式的多成分干预，并在资源匮乏的环境中可持续发展。通过与家庭保健护理的合作，以及使用家庭遥测反馈和强化治疗，我们将增加通常的临床服务，以改善未能达到治疗目标的糖尿病患者的健康结果。该建议是针对糖尿病并发症的二级预防，目标人群以健康差异和这种慢性疾病的高负担而闻名。

DESCRIPTION (provided by applicant): Many primary care patients, especially in inner-city settings, do not achieve targets for blood pressure and glycemic control. There is an urgent need to enhance treatment for those who do not reach goals within the usual clinical care system. We propose to develop a multi-component intervention grounded in the Chronic Care Model, and sustainable in resource-challenged settings. Through collaboration with home health nursing and with the use of home telemetry for feedback and intensification of therapy, we will augment usual clinical services to improve health outcomes for diabetes patients who have not been able to reach therapeutic goals. There are three specific aims. First, we will establish a feasible, practical and sustainable collaborative model between the primary care sites of our practice-based research network (NYC RING), clinical researchers at the Diabetes Research and Training Center, and The Montefiore Home Health Organization, integrating the unique expertise of each of the partners and defining the roles and responsibilities of each. Second, we will develop and refine the components of the intervention, to include training primary care providers and home health nurses to integrate the technical, psychosocial and communication processes for implementation of the intervention. Third, we will assess the feasibility of the collaborative intervention by implementing the intervention for 25 primary care patients and obtain preliminary estimates of effectiveness by comparing outcomes to 25 patients receiving usual care. Our proposal includes plans to develop feasible procedures for data collection, with qualitative and quantitative methods of assessing process and outcome measures. We will use these preliminary data to revise the intervention and prepare an R18 application to further develop and test the intervention in multiple inner- city primary care sites serving low-income diabetes patients. This proposal is for secondary prevention of diabetes complications, targeting a population known for health disparities and a high burden from this chronic disease. Many primary care patients, especially in inner-city settings, do not achieve targets for blood pressure and glycemic control. We propose to develop a multi-component intervention grounded in the Chronic Care Model, and sustainable in resource- challenged settings. Through collaboration with home health nursing and with the use of home telemetry for feedback and intensification of therapy, we will augment usual clinical services to improve health outcomes for diabetes patients who have not been able to reach therapeutic goals. This proposal is for secondary prevention of diabetes complications, targeting a population known for health disparities and a high burden from this chronic disease.