My Diabetes My Community

项目摘要 患有糖尿病的老年非裔美国人是一个非常脆弱的人群。除了高敏感性外， 在COVID-19等外部损伤中，这一人群的心血管和微血管疾病发病率最高， 并发症以及不良药物事件如低血糖症。为了满足这一独特需求， 人口，多个组织呼吁个性化的方法来设定风险因素的目标和自我， 考虑合并症、功能状态和社会经济风险的护理计划。尽管人们普遍 同意，这种高度个性化的方法对老年糖尿病护理的临床影响很少 在对照试验中研究。旨在个性化糖尿病护理的干预措施必须克服多种障碍， 实施的挑战包括简短的临床就诊，就诊之间缺乏接触， 以及缺乏利用社区自我保健资源的系统。我们建议解决这些知识 通过研究两种循证干预措施的整合，管理糖尿病， 更积极生活的机会（我的糖尿病目标）和社区处方。我的糖尿病目标 干预旨在使老年患者参与个性化目标设定和慢性病管理。 干预措施包括对健康状况、低血糖风险、护理障碍和 通过电子健康记录（EPIC®）患者门户（MyChart®）提供的治疗偏好。糖尿病 护士与患者一起审查调查结果，以达到个性化的糖尿病目标，并每月提供 电话护理管理。CommunityRx可显著增强护士护理管理 (CRx)，是一个社区资源转介信息系统，是与 部门和当地居民。在遭遇期间，会生成HealtheRx，包括满足基本需求的资源 如食物和住房、身心健康、疾病自我管理和康复。各地 芝加哥大学实践网络，我们将进行为期12个月的三臂平行语用随机 600例受试者的对照试验，比较（1）糖尿病护理与（2）我的糖尿病目标与（3）我的糖尿病目标 + CommunityRx.在试验期间，我们将（1）评估My Diabetes GOAL Arms与Medial Care的影响 关于个性化糖尿病护理的过程（例如，关于糖尿病护理目标的决策冲突），（2） 评估三个研究组对自我效能、自我护理和社区服务利用的相对影响。 资源和（3）评估三个研究组对临床结果的相对影响（例如，血糖控制， 低血糖、老年疾病、功能状态）和医疗保健利用（艾德访视和计划外 住院）。然后，我们将对关键的试验经验进行混合方法评估。 利益攸关方群体。采用可扩展策略对老年非裔美国患者进行个性化糖尿病护理， 承认个人偏好，自我照顾和社区联系的障碍有可能改善 生活质量，同时避免药物不良事件。

PROJECT SUMMARY Older African Americans with diabetes are a highly vulnerable population. In addition to high susceptibility to external insults such as COVID-19, this population suffers the highest rates of cardiovascular and microvascular complications as well as adverse drug events such as hypoglycemia. To address the unique needs of this population, multiple organizations have called for a personalized approach to setting risk factor goals and self- care plans that account for comorbidities, functional status, and socioeconomic risks. Despite widespread agreement, the clinical impact of this highly personalized approach to geriatric diabetes care has rarely been studied in controlled trials. Interventions designed to personalize diabetes care must overcome multiple challenges to implementation including the brief clinical encounter, lack of engagement between encounters, and lack of systems to leverage community-based self-care resources. We propose to address these knowledge and care gaps by studying the integration of two evidence-based interventions, Managing Diabetes to Gain Opportunities for a More Active Life (My Diabetes GOAL) and CommunityRx. The My Diabetes GOAL intervention is designed to engage older patients in personalized goal setting and chronic disease management. The intervention consists of an initial assessment of health status, hypoglycemia risk, barriers to care, and treatment preferences delivered via the electronic health record (EPIC®) patient portal (MyChart®). A diabetes nurse reviews the survey results with the patient to arrive at personalized diabetes goals and provides monthly telephonic care management. Nurse care management may be significantly enhanced with CommunityRx (CRx), a community resource referral information system, developed in partnership with stakeholders across sectors and local residents. During encounters, a HealtheRx is generated, including resources for basic needs such as food and housing, physical and mental wellness, disease self-management and caregiving. Across the University of Chicago Practice Network, we will conduct a 12-month three-arm parallel pragmatic randomized controlled trial of 600 subjects comparing (1) Usual Care vs. (2) My Diabetes GOAL vs. (3) My Diabetes GOAL + CommunityRx. During the trial, we will (1) evaluate the impact of My Diabetes GOAL Arms versus Usual Care on processes of personalized diabetes care (e.g., decisional conflict regarding goals of diabetes care), (2) evaluate the relative impact of the three study arms on self-efficacy, self-care and utilization of community-based resources and (3) evaluate the relative effect of the three study arms on clinical outcomes (e.g., glycemic control, hypoglycemia, geriatric conditions, functional status) and health care utilization (ED visits and unplanned hospitalizations). We will then conduct a mixed-methods evaluation of the trial experience among key stakeholder groups. Personalizing diabetes care in older African American patients with scalable strategies that acknowledge personal preference, barriers to self-care and community connections have the potential to improve quality of life while avoiding adverse drug events.