Comparing the Effectiveness of Diabetes Care Interventions in Safety Net clinics

描述(由申请人提供)：拟议的项目涉及AHRQ的优先事项，即澄清最有效的初级保健重新设计战略，以提高慢性病护理的质量。尽管糖尿病造成了巨大的疾病负担，但人们对提高护理质量的交付系统战略的比较有效性知之甚少，这些战略在财务上是可行的，可以让社区诊所和卫生中心(CCHC)融入常规业务。组织护理以支持有效的糖尿病风险因素管理对许多CCHC来说尤其具有挑战性，他们为高比例的未参保患者提供服务，与投保患者相比，这些患者较少融入CCHC实践。拟议项目的目的是比较两种策略的有效性，这两种策略越来越多地被用于改善糖尿病和其他慢性病患者的护理质量--由医务助理在办公室进行的病人小组管理，以及由社区卫生工作者进行的基于社区的护理管理。圣克拉拉、洛杉矶和圣地亚哥县的18个加州CCHC站点将把其中一个新角色整合到他们的初级保健实践中，或者作为对照诊所，为大约9900名糖尿病患者提供服务。在实施前和实施后的12个月期间，研究人员将检查和比较干预对糖尿病护理质量、患者自我管理和患者的初级护理体验的影响。为了评估医疗助理小组经理和社区卫生工作者有效组织整合的促进者和障碍，该研究进一步试图描述选定的CCHC属性对每个干预措施的有效性的修改，包括组织对变化的准备、护理团队功能和结构能力。通过研究基线组织因素对CCHC越来越多地使用的糖尿病护理质量改进策略成功的影响，这项研究有可能(1)告知未来旨在改善安全网诊所慢性病护理的战略的性质和目标，以及(2)为从业者和政策制定者提供重要工具，以识别和干预提高或阻碍实施有效性的组织影响。该项目的目标是提供关于实施实践重新设计战略的概括性信息，其结果是组织变化，以及它们对糖尿病护理质量、患者自我管理以及患者对弱势人群的初级保健的体验的影响。 公共卫生相关性：尽管糖尿病造成了巨大的疾病负担，但人们对旨在提高社区诊所和卫生中心(CCHC)为弱势患者群体服务的糖尿病护理质量的干预措施的相对有效性知之甚少。药剂师主导的药物管理和护士病例管理等干预措施的有效性已经得到证明，但对于大多数CCHC来说，广泛采用这些方法来提高糖尿病护理质量在财务上是不可行的。拟议的项目旨在比较医务助理小组经理和社区卫生外展工作者的有效性，这是两种相对低成本的干预措施，旨在提高CCHC的糖尿病护理质量，并检查干预有效性的组织促进者。

DESCRIPTION (provided by applicant): The proposed project addresses AHRQ's priority of clarifying the most effective primary care redesign strategies for improving the quality of chronic illness care. Despite the large disease burden of diabetes, little is known about comparative effectiveness of delivery system strategies for improving care quality that are financially feasible for community clinics and health centers (CCHCs) to integrate into routine operations. Organizing care to support effective diabetes risk factor management has been particularly challenging for many CCHCs who serve high proportions of uninsured patients that are less integrated into CCHC practices compared to insured patients. The proposed project aims to compare the effectiveness of two strategies increasingly used by CCHCs for improving the quality of care patients with diabetes and other chronic illnesses receive- office-based patient panel management by medical assistants and community-based care management by community health workers. Eighteen California CCHC sites serving an estimated 9,900 patients with diabetes across Santa Clara, Los Angeles, and San Diego counties will be integrate one of the new roles into their primary care practice or serve as a control clinic. Intervention effects on diabetes care quality, patient self-management, and patients' experiences of primary care will be examined and compared across the study arms for 12-month periods pre- and post-implementation. In order to assess the facilitators and barriers to the effective organizational integration of medical assistant panel managers and community health workers, the study further seeks to describe the modification of each intervention's effectiveness by selected CCHC attributes, including organizational readiness to change, care team functioning, and structural capabilities. By examining the influence of baseline organizational factors on the success of diabetes care quality improvement strategies increasingly used by CCHCs, the research has potential to (1) inform the nature and targeting of future strategies aimed at improving chronic illness care in safety net clinics, and (2) provide practitioners and policy makers with important tools for identifying and intervening on organizational influences that enhance or impede implementation effectiveness. The goal of the project is to provide generalizable information about the implementation of practice redesign strategies, their resulting organizational changes, and their impact on the quality of diabetes care, patient-self-management, and patients' experiences of primary care for vulnerable populations. PUBLIC HEALTH RELEVANCE: Despite the large disease burden of diabetes, very little is known about the comparative effectiveness of interventions aimed at improving the quality of diabetes care in community clinics and health centers (CCHCs) that serve vulnerable patient populations. The effectiveness of interventions like pharmacist-led medication management and nurse case management has been demonstrated, but the broad uptake of these approaches for improving diabetes care quality is not financially feasible for most CCHCs. The proposed project aims to compare the effectiveness of medical assistant panel managers and community health outreach workers- two relatively low cost interventions aimed at improving the quality of diabetes care in CCHCs, and to examine the organizational facilitators of intervention effectiveness.