Glucose to Goal: A Model to Support Diabetes Management in Primary Care
Condition: Diabetes Mellitus
MeSH terms: Diabetes Mellitus
Study type: Interventional

Summary: 
      Diabetes education is a very important part of diabetes care. Most people with diabetes
      receive care in primary care practices where diabetes education is not always available. This
      project tests a model designed to improve access to diabetes education services.
    

Detailed description: 
      Evidence that diabetes self-management education (DSME) can improve health outcomes has
      repeatedly been shown and is considered to be a critical component of care. Diabetes
      educators are highly skilled at addressing diabetes-related clinical and behavioral needs
      through DSME, but engagement with diabetes educators is underutilized. It has been suggested
      that poor referral practices and the way in which DSME service is delivered are the problems.
      Most patients receive diabetes care in primary care yet most DSME programs are distinctly
      separate from primary care practice. This limits care coordination and diabetes educator
      access to amenities currently available to primary care. Efforts are underway to change the
      US health care paradigm with a focus on quality in primary care that includes practice
      redesign, population management, and communication through electronic medical records. The
      purpose of this application is to evaluate the deployment of Glucose to Goal, a model relying
      on a systematic redesign of practice that links diabetes educators services with primary
      care. This will be compared to the traditional process for DSME delivery, without the direct
      connection to primary care processes, for an eighteen month period. The hypothesis is that
      the proportion of primary care provider referrals and patient utilization of diabetes
      educator services from primary care practices participating in Glucose to Goal will be higher
      compared to those associated with traditional DSME. It is anticipated that this model will
      appeal to primary care providers, demonstrate a feasible approach to offering diabetes
      education in the current health environment, and set the stage for future testing of the
      model, namely its impact on meaningful improvements on diabetes outcomes and
      cost-effectiveness.
    

Intervention name(s): Glucose to Goal; Usual Care
Intervention type(s): Other; Other
Intervention description(s): The Glucose to Goal intervention applies elements of the Patient Centered Medical Home (i.e., practice design, decision support, population management, etc) to diabetes education services and operationalizes the current DSME objectives in the primary care setting.; The control group will follow the traditional DMSE delivery model, which includes primary care providers referring patients to an outpatient, hospital-based diabetes educator for DSME, but in a passive manner (i.e., without proactive patient identification), which is the usual process for referrals.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Diabetes Education; Chronic Disease Management; Health Care Delivery; Patient-Centered Medical Home; Primary Care