Integrated Community-Clinical Linkage Model to Promote Weight Loss among South Asians with Pre-Diabetes

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PROJECT SUMMARY The proposed project will build on a well-established collaboration between researchers at the NYU School of Medicine, HealthFirst (largest Medicaid insurer in NYC), New York City Department of Health and Mental Hygiene, clinical practices, and community partners to promote diabetes prevention among NYC South Asians. The goal of this study is to test the effectiveness and assess the implementation process of an integrated intervention to support weight loss for South Asian patients at risk for Type 2 Diabetes Mellitus (T2DM) in primary care settings. The integrated intervention has two components: an electronic health record (EHR)- based component to increase screening and identification of South Asian patients who are at-risk of T2DM; and 2) A registry-driven community health worker (CHW)-led health coaching component. Using a stepped- wedge design, we will implement the study in 25 NYC primary care practice (PCPs) sites enrolling 2,840 South Asian patients at- risk for T2DM. The project has two specific aims. First, we will test the effectiveness of an integrated EHR-based intervention (ie. an alert to screen at-risk patients and a registry function to track outcomes) plus CHW-led coaching of registered patients compared with usual care. The primary outcome is >5% weight loss among South Asian patients at-risk for T2DM. Second, using a mixed-methods approach and the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) evaluation framework, we will systematically assess the implementation process and delineate factors that influence adoption, sustainability, and scalability of an integrated EHR-CHW intervention within applied practice settings. The integrated EHR-CHW protocol will support team-based care by allowing for feedback between providers and CHWs, who will be providing health education to participants while actively participating in patient management with providers.