Comparing the Effectiveness of Diabetes Care Interventions in Safety Net clinics

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DESCRIPTION (provided by applicant): The proposed project addresses AHRQ's priority of clarifying the most effective primary care redesign strategies for improving the quality of chronic illness care. Despite the large disease burden of diabetes, little is known about comparative effectiveness of delivery system strategies for improving care quality that are financially feasible for community clinics and health centers (CCHCs) to integrate into routine operations. Organizing care to support effective diabetes risk factor management has been particularly challenging for many CCHCs who serve high proportions of uninsured patients that are less integrated into CCHC practices compared to insured patients. The proposed project aims to compare the effectiveness of two strategies increasingly used by CCHCs for improving the quality of care patients with diabetes and other chronic illnesses receive- office-based patient panel management by medical assistants and community-based care management by community health workers. Eighteen California CCHC sites serving an estimated 9,900 patients with diabetes across Santa Clara, Los Angeles, and San Diego counties will be integrate one of the new roles into their primary care practice or serve as a control clinic. Intervention effects on diabetes care quality, patient self-management, and patients' experiences of primary care will be examined and compared across the study arms for 12-month periods pre- and post-implementation. In order to assess the facilitators and barriers to the effective organizational integration of medical assistant panel managers and community health workers, the study further seeks to describe the modification of each intervention's effectiveness by selected CCHC attributes, including organizational readiness to change, care team functioning, and structural capabilities. By examining the influence of baseline organizational factors on the success of diabetes care quality improvement strategies increasingly used by CCHCs, the research has potential to (1) inform the nature and targeting of future strategies aimed at improving chronic illness care in safety net clinics, and (2) provide practitioners and policy makers with important tools for identifying and intervening on organizational influences that enhance or impede implementation effectiveness. The goal of the project is to provide generalizable information about the implementation of practice redesign strategies, their resulting organizational changes, and their impact on the quality of diabetes care, patient-self-management, and patients' experiences of primary care for vulnerable populations. PUBLIC HEALTH RELEVANCE: Despite the large disease burden of diabetes, very little is known about the comparative effectiveness of interventions aimed at improving the quality of diabetes care in community clinics and health centers (CCHCs) that serve vulnerable patient populations. The effectiveness of interventions like pharmacist-led medication management and nurse case management has been demonstrated, but the broad uptake of these approaches for improving diabetes care quality is not financially feasible for most CCHCs. The proposed project aims to compare the effectiveness of medical assistant panel managers and community health outreach workers- two relatively low cost interventions aimed at improving the quality of diabetes care in CCHCs, and to examine the organizational facilitators of intervention effectiveness.