Medical Assistant Health Coaching for Diabetes in Diverse Primary Care Settings

 糖尿病影响着美国近2600万人，如果目前的趋势继续下去，到2050年，三分之一的成年人将患有糖尿病。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参与率很低，特别是在服务不足的人群中，通常需要持续的支持来维持DSME的收益。糖尿病患者的复杂需求无法在典型的15分钟初级保健访问中得到充分解决。通过采用“基于团队”的方法，即慢性病护理模式，其他初级保健人员[例如，医疗助理]可以被培训为健康教练，与初级保健提供者合作，提供自我管理支持。虽然研究有限，但一些研究表明，MA提供的自我管理支持可以改善糖尿病患者的预后。这项拟议的随机分组、对照、实用性试验将在600名18岁及以上的2型糖尿病（T2 DM）患者中比较MA健康指导（MAC）与常规护理（UC）在改善糖尿病临床控制方面的有效性，这些患者糖化血红蛋白（HbA 1c）= 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在过去的60天内，该研究将在两个卫生系统的初级保健诊所内进行，这些卫生系统为圣地亚哥县的大型，种族/种族和社会经济多样化的人群提供服务：社区医疗保健（一个社区医疗保健）和Scripps（一个大型，非营利性，基于私人保险的卫生系统）。每个系统内的一个诊所将被随机分配到MAC，一个分配到UC。除了常规护理外，MAC诊所的患者还将获得MA健康教练的简短、有针对性的自我管理支持。MA在实现MAC元素（即，健康行为评估、药物协调、动机访谈、议程和目标设定、解决问题、“闭环”技术以确保对建议的理解），并将使他们对这些组件的使用适应患者的特定需求和优先级。根据需要，MA将协调简短的电话随访，以审查进展和解决任何障碍的问题。电子健康记录将用于识别合格患者，并检查12个月内糖尿病临床结局（HbA 1c、LDL、SBP）的变化。在基线、第6个月和第12个月时，将通过电话评估MAC和UC受试者子集（N=300）中患者报告的行为（糖尿病自我护理）和心理社会（生活质量、患者激活）结局的变化。在覆盖、有效性、采用、实施和维护（RE-AIM）框架的指导下进行的评估以及对计划成本的审查将评估可持续性和可扩展性的潜力。MAC计划为新兴的初级保健需求能力不平衡提供了一种潜在的解决方案，可应用于不同的医疗保健环境，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.