Patient Activation Through Community Empowerment/Engagement for Diabetes Management (PACE-D)
Condition: Diabetes Mellitus; Chronic Disease; Patient Care Planning; Patient Participation; Self Care; Empowerment
MeSH terms: Diabetes Mellitus; Chronic Disease
Study type: Interventional

Summary: 
      The study is a non-randomised controlled trial involving an intervention group and a control
      group. It aims to evaluate the effects of a patient engagement and empowerment model of
      collaborative care support planning on clinical outcomes of patients with diabetes mellitus
      as compared to usual care in the primary care setting. It also aims will be to examine the
      impact of the intervention on patient activation, patient and healthcare provider experience,
      and healthcare utilisation.
    

Detailed description: 
      The investigators will conduct a prospective study on existing patients with diabetes who are
      on follow-up with their teamlets at Pioneer (PIO), Jurong (JUR), Bukit Batok (BBK) and Choa
      Chu Kang (CCK) polyclinics for management of diabetes. Recruitment will occur for 18 months
      from the time of study implementation. One teamlet in JUR and one teamlet in PIO (total of
      two teamlets) will fall under intervention arm where the new care model based on the
      Year-of-Care (YOC) model will be delivered, whereas one teamlet in BBK and one teamlet in CCK
      (total of another two teamlets) will fall under the control arm where the current teamlet
      model will be continued.

      In the intervention group, patients recruited will undergo the new care model which entails
      receiving the Care Planning Results Letter before the consultation at their annual review,
      involving them in the Care and Support Planning (CSP) consultation at the annual review, and
      referring them to suitable community resources to support self-management. The Care Planning
      Results Letter prompts patients to think the issues they would like to raise to their Doctor
      or Care Manager (who is a nurse trained in chronic disease management), checks on their mood,
      provides information on their most recent few laboratory test results, clinical parameters,
      smoking status, and attendances for foot and eye screenings. The letter also covers goal
      setting and action planning discussions. The patient is expected to bring it for the upcoming
      CSP consultation at the annual review. The CSP is a conversation which is conducted by the
      Doctor or Care Manager trained in the new care model. It focuses on a collaborative approach
      between the health care providers and the patient for joint goal setting and shared decision
      making to support self-management of their chronic condition(s).

      In the control arm, the participants will receive the usual care with the teamlet model.
      There will not be any Care Planning Results Letter prepared for the patient. At the upcoming
      annual visit, the patient will continue to have the usual annual review for the laboratory
      test results and consultation. A flyer that lists the community programmes that support the
      patient for self-management will also be issued to the patient. If the patient is interested
      in any of these programmes, they may sign up with the respective community providers
      directly.

      After the first CSP, selected patient participants may be invited for a one-to-one in-depth
      interviews (IDIs) to explore their perceptions about diabetes, diabetes management and the
      intervention programme in greater detail. The interviews will be conducted by researchers
      trained qualitative research methodology. They will be semi-structured with a topic guide to
      support exploration of the themes of interest, and will be informed by prior qualitative
      research with this and other similar interventions, as well as the results from the patient
      surveys. Health care providers who are involved in the delivery of CSPs in the intervention
      arm will also be invited for a one-to-one in-depth interviews (IDIs), to develop an
      understanding of how they find the training and new way of working with patients
      (particularly the care and support planning conversation).
    

Intervention name(s): Intervention Group; Control Group
Intervention type(s): Other; Other
Intervention description(s): Participants in this arm will undergo the new care model for management of diabetes mellitus polyclinics.; Participants in this arm will continue to undergo the existing care model for management of diabetes mellitus in the polyclinics.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: Non-randomised controlled trial
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Diabetes; Long term conditions; Chronic disease management; Patient engagement; Patient empowerment; Self-management; Care Planning