A multi-level intervention to increase access and use of patient portals for diabetes management in community health centers (MAP)

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Abstract In the US, there are significant health care disparities in the prevalence, morbidity, and mortality of type 2 diabetes (T2D) in racial and ethnic minority populations. Increased patient portal use, such as accessing medical records and secure messaging with providers has the potential to improve engagement with care and diabetes health outcomes. Yet, there are substantial disparities in portal use by adults who are of diverse race/ethnicity and with limited socioeconomic resources. Over 1,400 community health centers (CHCs) in the US provide comprehensive health care to adults of diverse races and ethnicities in underserved communities and play a critical role in addressing health inequities in T2D care. We propose to develop a multi-level intervention to increase access and use of patient portals for diabetes management (MAP) in community health centers (CHC) aligned with the World Health Organization (WHO) Social Determinants of Health Equity framework. The intervention will: 1) provide free access to tablets and internet (material circumstances); 2) technology training and ongoing support (psychosocial factors); 3) assess social determinants of health and refer to community resources (material circumstances); and, 4) support diabetes self-management behaviors and refer to clinic services (behavioral and biological factors). MAP will be delivered by community health workers (CHW) and nurses already embedded in CHCs (healthcare system). The study aims are to: 1) Optimize components of the MAP intervention for adults with T2D who access healthcare at CHCs by conducting focus groups/interviews with adults with T2D and health care providers (n=24) from two CHCs using established qualitative methods; and 2) determine the effect size of MAP use for adults with T2D at two CHCs (n=36) on the primary outcomes of portal use and A1C and secondary outcomes of: a) patient engagement with care, T2D self-management, and psychosocial outcomes. Using a within subjects, pre-post design we will pilot MAP in adults with T2D who are portal naive. We will use generalized linear mixed model (GLMM), incorporating correlations among repeated measures (baseline, 3 months, and 6 months) to analyze data. We will evaluate portal use factors associated with improvement in outcomes. We will rigorously evaluate the feasibility of MAP (acceptability, demand, implementation, adaptation, and integration) using an established framework and mixed methods. Lastly, we will explore the use of publicly available diabetes and health resources on the internet by adults with T2D when provided access to a tablet and internet. Results of this study will have important implications on the potential of a novel multi-level intervention provided in CHCs to improve patient portal use, diabetes self-management, and glycemic control in adults of diverse race/ethnicity with limited socioeconomic resources.