Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effectiveness of Care Coordination in Managing Medically Complex Patients
Brief Summary: Patients treated at Veterans Affairs (VA) medical centers are older and have multiple chronic conditions. Two of the most common conditions in the VA population are hypertension (HTN) and Type 2 diabetes (DM). Unfortunately, DM and HTN have few perceptible symptoms on a daily basis that motivate patients to comply with treatment recommendations and lifestyle changes. Thus, serious complications and long-term adverse outcomes are common in both of these conditions.

Home telehealth is a general term used to describe the delivery of health care services to the patient's home using audio, video, or other telecommunications technologies. Although home telehealth offers a number of theoretical advantages, few well-designed controlled clinical trials have been conducted to establish efficacy and cost benefit. Furthermore, projects to date have focused on special populations, e.g., heart failure or mental illnesses. Since home telehealth may hold the most promise for individuals dealing with multiple chronic illnesses, there is a need for population-based studies addressing the needs of patients in primary care settings.

Care coordination, as defined by the VHA Office of Care Coordination, is a process of assessment and ongoing monitoring of patients using home telehealth to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate use of resources. Care coordination embeds technology into a care management process. This results in the right care, at the right time, in the right place.


Options:
A: Inclusion Criteria:

Patients must obtain their primary care at the Iowa City VAMC and have been diagnosed with Diabetes Mellitus and hypertension. Must be cognitively intact and have a telephone line in the home.

Exclusion Criteria:

Patients with corrected vision worse than 20/40 or cognitive impairment (Mini-Mental Status Exam score of 17 or less) will not be eligible.
B: Inclusion Criteria:

* Minimum six months post-diagnosis of type 2 diabetes age between 35 and 75 years
* Treated by diet alone, oral hypoglycaemic medications, insulin or combination therapy
* No documented PA limitations
* Dutch speaking
* Having a telephone number
C: Inclusion Criteria:

1. Clinical Diagnosis of Type 2 diabetes mellitus
2. Glycosylated Hemoglobin (HbA1c) \> 7.0 = Uncontrolled
3. Positive score on diabetes related distress 2 question screener and/or
4. Positive score on Patient Health Questionnaire (PHQ-2) 2 question screener

Exclusion Criteria: a diagnosis \[from billing records using International Classification of Disease, 9th Edition (ICD-9) codes\] of:

1. advanced disease (e.g., end stage renal disease, advanced heart failure, blindness, metastatic cancer and including those who are in active treatment for cancer), or
2. alcoholism or
3. cognitive impairment, or
4. major psychiatric disease or
5. any type of physical or mental impairment that would preclude active participation
D: Inclusion Criteria:

1. Adults, 18 years or older, currently being treated for Type II diabetes
2. HgbA1C greater or equal to 8.0% and at least 1.0% above target within the last 3 months
3. Have a functional email address or be willing to obtain one
4. Be functional in reading the English language (self reported)

Exclusion Criteria:

1. Have Type I diabetes or Latent autoimmune diabetes of adults (LADA)
2. Are on continuous glucose monitoring
3. Have an insulin pump
4. Are on dialysis
5. Are pregnant.
6. Are unable to use a computer or mobile phone due to severe mental or physical impairment

Answer: A