Addressing Basic Needs to Improve Diabetes Outcomes in Medicaid Beneficiaries

2型糖尿病影响着2900多万美国成年人，低收入人群承担的疾病负担不成比例 收入人口。有效的自我管理需要关注、计划、贯彻和一致 实施多种健康行为，预防负面健康后果。对于低收入个人来说， 然而，健康状况的改善往往被满足基本需求的努力所取代，如食物、住房、 人身安全和生活必需品的钱。没有得到满足的基本需求压倒了一个人的能力 保持健康的行为。我们之前的研究表明，随着更多的基本需求得不到满足， 收入的个人甚至不太可能记得，更不用说根据转介来获得所需的医疗服务了。 然而，当未得到满足的需求得到解决和/或人们有个人导航员来帮助时， 对健康转诊采取行动的人数显著增加。传统上，患者导航器帮助协调护理， 管理疾病或促进筛查和预防行为。我们建议将这一角色扩大到包括 确定和解决未得到满足的基本需求，我们预计这将促进行为的改变和改进 健康结果。我们将在与以下机构合作进行的务实随机试验中测试这种方法 路易斯安那州Healthcare Connections，路易斯安那州最大的医疗补助管理式医疗计划。具体来说，我们 提出一项多学科、多方法的研究，有三个目标：使用观察法，我们将 检查医疗补助成员经历的基本需求的类型和数量，以及这些需求如何 通过将基本需求数据与索赔数据相关联，随时间影响健康结果和医疗保健利用率 (目标1)。在一项务实的随机试验中，我们将测试有效性(目标2)和成本效益(目标2 3)对500名成年人(18-75岁)的基本需求导航干预与常规护理进行比较 医疗补助，2型糖尿病，以及一种或更多未得到满足的基本需求。主要的假设是，干预 与常规护理相比，参与者在岗前糖化血红蛋白的下降幅度更大(M=0.5% 参与者。与我们关于未得到满足的基本需求对健康结果的影响的概念模型一致， 我们还将检查自我照顾的障碍(例如，注意力、压力、睡眠)、健康行为(例如，葡萄糖 监测、饮食、临床筛查)和二次健康结果(例如，急诊科 利用、住院、生活质量)。路易斯安那州医疗保健连接将确定符合条件的成员 研究招聘并提供6个月的基本需求导航。研究团队将招募，招募， 在基线和3个月、6个月和12个月的随访时通过电话随机调查研究参与者。全 HbA1c数据将从基线前1-3个月至12个月的电子病历中获得 在基线后几个月评估变化。如果有效且具有成本效益，干预将加速 通过路易斯安那州Healthcare Connections的母公司Centene Corporation， 它是美国最大的医疗补助管理保健公司，在其他28个州拥有医疗补助计划。

Type 2 diabetes affects over 29 million US adults, with a disproportionate burden of disease borne by low- income populations. Effective self-management requires attention, planning, follow-through and consistent performance of multiple health behaviors to prevent negative health outcomes. For low-income individuals, though, health improvement is often superseded by the drive to fulfill basic needs such as food, housing, personal safety, and money for necessities. Having unmet basic needs overwhelms a person’s ability to maintain health behaviors. Our prior research has demonstrated that with more unmet basic needs, low- income individuals are less likely to even remember let alone act on a referral for needed health services. However, when unmet needs are resolved and/or people have a personal navigator to help, the likelihood of acting on a health referral significantly increases. Traditionally, patient navigators help coordinate care, manage disease or promote screening and preventive behaviors. We propose expanding this role to include identifying and resolving unmet basic needs, which we expect will facilitate behavior change and improve health outcomes. We will test this approach in a pragmatic randomized trial conducted in partnership with Louisiana Healthcare Connections, the largest Medicaid managed care plan in Louisiana. Specifically, we propose a multi-disciplinary, multi-method study with three aims: Using observational methods, we will examine the type and number of basic needs experienced by Medicaid members, and how those needs impact health outcomes and healthcare utilization over time by linking basic needs data with claims data (Aim 1). In a pragmatic randomized trial, we will test the effectiveness (Aim 2) and cost-effectiveness (Aim 3) of a basic needs navigation intervention compared to usual care among 500 adults (ages 18-75) with Medicaid, type 2 diabetes, and 1 or more unmet basic needs. The primary hypothesis is that intervention participants will have a greater reduction (M=0.5%) in HbA1c pre-post compared with usual care participants. Consistent with our conceptual model of the effects of unmet basic needs on health outcomes, we also will examine barriers to self-care (e.g., attention, stress, sleep), health behaviors (e.g., glucose monitoring, diet, clinical screenings) and secondary health outcomes (e.g., emergency department utilization, hospitalization, quality of life). Louisiana Healthcare Connections will identify eligible members for study recruitment and provide basic needs navigation for 6 months. The research team will recruit, enroll, randomize, and survey study participants by phone at baseline and 3-, 6- and 12-month follow up. All HbA1c data will be obtained from electronic medical records between 1-3 months pre-baseline and 12 months post-baseline to assess change. If effective and cost-effective, the intervention has an accelerated path to wide diffusion through Louisiana Healthcare Connections’ parent company, Centene Corporation, which is the largest Medicaid managed care company in the U.S., with Medicaid plans in 28 other states.