primary care based integrated community care team intervention

Conditions: Diabetes; Diabetes Mellitus; Diabetes Mellitus, Type 2; Diabetes type2

Summary: pace-it study is a non-blinded, mix-method randomized controlled trial within a single site. this study aims to test the feasibility of implementing a complex intervention comprising of a) a primary care based integrated community care team delivery of person centered care, b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with diabetes and have complex needs.

pace-it study aims to test the feasibility of implementing a complex intervention comprising of a) a primary care based community care team delivery of person centered care b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with diabetes and complex needs. this is a non-blinded, mix-method randomised controlled trial within the marine parade community. the primary outcome will be glycemic control measure by the glycated haemoglobin (hba1c). secondary outcomes include blood pressure, ldl-cholesterol, patient activation measure, medication adherence and quality of life. data on patient and provider satisfaction and implementation process will be collected by the qualitative method.

Eligibility criteria:
inclusion criteria: * living within the designated geographical zone * 50 years and above * satisfy the medical criteria below: 1. diabetes with hba1c ≥ 9% (within past 6 months), and 2. at least 1 complication 1. chronic kidney impairment stage 3 and above, or diabetes overt nephropathy, 2. ischaemic heart disease, or congestive cardiac failure, 3. peripheral arterial disease, or diabetes foot/ diabetes foot-related complications, 4. diabetic retinopathy/ treatment for retinopathy, and 5. stroke, or transient ischaemic attack * satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain: 1. psycho-social issues a. lack of care giver support i. no care-giver (when indicated) ii. care-giver skills gap/ stress iii. inability of copy when patient is the care-giver b. difficult relationships (family/ workplace/ social network) c. social isolation/ lack of social connectivity i. lives alone ii. lack of social network support d. financial i. financial difficulty/ insecurity ii. housing/ shelter issues iii. poor money management 2. functional 1. clinical frailty score ≥ 4, requiring help in instrumental activities of daily living (iadl) 2. requires assistance in adl or iadl 3. activation a. lack of ability to manage health - disengaged or overwhelmed i. anxiety or disease-related distress ii. confusion or lack of understanding of care plans iii. non-adherence to medications/ follow up * patient gives consent to participate * for patients who may be seeing a primary care physician (pcp) outside of the polyclinic for chronic disease management and where the pcp has indicated consent to co-manage the patient with the pace-it team including the polyclinic physician * patient must be willing to receive care in the polyclinic exclusion criteria: * patients who are on follow up with primary care physicians or general practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the pace-it team * patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team * patients who are (i) not community ambulant or (ii) bed bound * patients with terminal illness * patients who have are in other programs or research studies * patients who do not give consent