Medical Assistant Health Coaching for Diabetes in Diverse Primary Care Settings

 描述(由申请者提供)：美国有近2600万人患有糖尿病，如果目前的趋势继续下去，到2050年，每3名成年人中就有1人患有糖尿病。糖尿病自我管理教育和支持(DSME)是改善临床控制和健康结果的有效护理的基石；然而，DSME的参与率很低，特别是在服务不足的人群中，而且经常需要持续的支持才能保持DSME的成果。糖尿病患者的复杂需求不能在通常15分钟的初级保健访问中得到充分解决。通过采用受慢性护理模式启发的“基于团队”的方法，其他初级保健人员[例如，医疗助理(MA)]可以作为健康教练接受培训，以便与初级保健提供者合作，提供自我管理支持。尽管研究有限，但几项研究表明，MA提供的自我管理支持改善了糖尿病的预后。这项拟议的整群随机、对照、务实试验将在过去60天内比较MA健康教练(MAC)和普通护理(UC)在改善糖尿病临床控制方面的有效性，对象为600人，年龄在18岁及以上，患有2型糖尿病(T2 DM)，糖化血红蛋白(HbA1c)=8.0%，和/或低密度脂蛋白胆固醇(LDL-C)=100 mg/dL，和/或收缩压(SBP)=140。这项研究将在两个卫生系统的初级保健诊所进行，这两个卫生系统服务范围很大，种族/种族，和圣地亚哥县多样化的社会经济人口：Neighborhood Healthcare(FQHC)和Scripps(一种基于私人保险的大型非营利性医疗系统)。每个系统中的一家诊所将随机分配给MAC，一家分配给UC。除了常规护理外，MAC诊所的患者还将从MA Health Coach那里获得简短的、有针对性的自我管理支持。医管局将在实施医管局要素(即健康行为评估、用药协调、动机面谈、议程和目标设定、解决问题、“闭合循环”技术以确保理解建议)方面获得灵活性，并将根据患者的具体需要和优先事项对这些要素的使用进行调整。根据需要，MA将协调简短的电话跟踪，以审查进展并绕过任何障碍解决问题。电子健康记录将用于识别符合条件的患者，并检查糖尿病临床结果(糖化血红蛋白、低密度脂蛋白、SBP)在12个月内的变化。患者报告的行为(糖尿病自我护理)和心理社会(生活质量，患者激活)结果的变化将通过电话评估在基线、6个月和12个月的MAC和UC参与者子集(N=300)中进行评估。由REACH、有效性、采用、实施和维护(RE-AIM)框架指导的评估以及对计划成本的检查将评估可持续性和可扩展性的潜力。MAC计划为迅速增长的初级保健需求-能力失衡提供了一个潜在的解决方案，可以应用于不同的保健环境，以更好地满足越来越多的T2 DM患者的需求。

 DESCRIPTION (provided by applicant): Diabetes affects nearly 26 million individuals in the U.S, and if current trends continue, 1 of 3 adults will have diabetes by 2050. Diabetes self-management education and support (DSME) is a cornerstone of effective care that improves clinical control and health outcomes; however, DSME participation is low, particularly among underserved populations, and ongoing support is often needed to maintain DSME gains. The complex needs of individuals with diabetes cannot be adequately addressed in the typical 15-minute primary care visit. By adopting a "team-based" approach that is informed by the Chronic Care Model, other primary care personnel [e.g., medical assistants (MAs)] can be trained as health coaches to work in tandem with primary care providers to deliver self-management support. Although research is limited, several studies have shown that MA-provided self-management support improves outcomes in diabetes. The proposed cluster-randomized, controlled, pragmatic trial will compare the effectiveness of MA Health Coaching (MAC) with usual care (UC) in improving diabetes clinical control among 600 individuals, aged 18 and older, with type 2 diabetes mellitus (T2DM), and glycosylated hemoglobin (HbA1c) = 8.0%, and/or low-density lipoprotein cholesterol (LDL-C) = 100 mg/dL, and/or systolic blood pressure (SBP) = 140 within the last 60 days The study will take place within primary care clinics of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in San Diego County: Neighborhood Healthcare (a FQHC) and Scripps (a large, non-profit, private insurance-based health system). One clinic within each system will be randomly allocated to MAC, and one to UC. In addition to usual care, MAC clinics patients will receive brief, targeted self-management support from the MA Health Coach. The MA will be afforded flexibility in their implementation of MAC elements (i.e., health behavior assessment, medication reconciliation, motivational interviewing, agenda- and goal-setting, problem- solving, "closing the loop" techniques to ensure understanding of recommendations), and will tailor their use of these components to patient-specific needs and priorities. As needed, MAs will coordinate brief phone follow- up to review progress and problem-solve around any barriers. Electronic health records will be used to identify eligible patients and to examine change in diabetes clinical outcomes (HbA1c, LDL, SBP) over 12 months. Changes in patient-reported behavioral (diabetes self-care) and psychosocial (quality of life, patient activation) outcomes will be evaluated by phone assessment in a subset (N=300) of MAC and UC participants at baseline, and months 6 and 12. An evaluation guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and an examination of program costs will assess potential for sustainability and scalability. The MAC program offers a potential solution to the burgeoning primary care demand-capacity imbalance that can be applied in diverse healthcare settings to better address the needs of the growing number of individuals with T2DM.