ACCTiVATE: Achieving Chronic Care equiTy by leVeraging the Telehealth Ecosystem

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PROJECT SUMMARY/ABSTRACT Chronic diseases such as hypertension, diabetes and chronic kidney disease cause significant mortality, with stark inequities impacting racially and ethnically minoritized populations. The COVID-19 pandemic prompted a rapid shift in chronic disease management to telehealth-based care, including patient portals, telemedicine video visits, and remote patient monitoring. However, there are substantial racial/ethnic and socioeconomic disparities in health IT access for chronic disease management in the United States. This is due to patient-level barriers such as inequitable device and internet access and lower digital literacy, as well as clinic-level barriers such as inadequate support to access digital technologies and skills, inequitable offering of health IT, and a lack of equity-focused, stratified telehealth data. Increasing telehealth use among minority populations has the potential to lessen disparities in chronic disease health outcomes. We propose a 2x2 randomized controlled trial entitled “Achieving Chronic Care equiTy by leVerAging the Telehealth Ecosystem” (ACCTiVATE), in which we will examine the impact of a multi-level intervention that tackles patient-level and clinic-level barriers to increase the equitable use of health IT for chronic disease management. The patient-level intervention combines the role of digital health navigator and chronic disease health coach to facilitate access to devices and broadband, offer digital skills training, and provide chronic disease health coaching focused on telehealth modalities. The clinic-level intervention includes Practice Facilitation with a learning collaborative, clinic-specific Community Advisory Boards, and electronic “Telehealth Equity Dashboards” that display telehealth utilization stratified by race/ethnicity. We will randomize 600 English- and Spanish-speaking adults with uncontrolled hypertension across 10 federally qualified health centers to digital coaching versus usual care. The 10 health centers will be randomized to Practice Facilitation versus usual care. In Aim 1, we will assess the impact of the multi-level intervention (coaching combined with practice facilitation, and each arm alone) on systolic blood pressure (primary outcome), hemoglobin A1c, and microalbuminuria overall, and among Black and Latinx patients. In Aim 2, we will assess impacts on process measures of telehealth disease management (digital literacy, medication adherence, engagement with health IT). In Aim 3, we will conduct a mixed methods evaluation of implementation by applying the RE-AIM framework to identify key features needed for successful adoption and dissemination by healthcare networks. A multidisciplinary Stakeholder Advisory Board will advise on all Aims. The proposed intervention recognizes the multilevel determinants that have perpetuated the digital divide, worsening chronic disease care during the pandemic. The impact of this intervention will result in an efficient, user-centered multilevel intervention for improved telehealth engagement, medication adherence, and digital literacy, which are all key drivers of improved chronic disease outcomes.