MedStar Health Type 2 Diabetes Pathway to Control
Condition: Type 2 Diabetes Mellitus; Hyperglycemia
MeSH terms: Diabetes Mellitus; Diabetes Mellitus, Type 2; Hyperglycemia
Study type: Interventional

Summary: 
      A Diabetes Institute (MDI), in partnership with key stakeholders-including Primary Care
      Providers- in a northeastern US regional, mixed-payer healthcare system), seeks to implement
      an evidence-based, technology-enabled, innovative, and integrated diabetes care management
      pathway (Boot Camp) for adult patients with uncontrolled type 2 diabetes (A1C>/=9%) which
      will demonstrate improvement in diabetes clinical and health resources utilization outcomes.
    

Detailed description: 
      -  The program is designed to integrate type 2 diabetes specialty services into Primary
           Care practices to support PCPs and their patients in improving a spectrum of
           diabetes-related outcomes.

        -  High-risk patients from Primary Care practices who have uncontrolled type 2 diabetes and
           meet the target population inclusion and exclusion criteria will be invited to
           participate in an intensive and concise "BOOT CAMP" medication management and education
           intervention of ~4-8 weeks duration.

        -  The intervention will consist of three key components: (1) intensive, algorithm-based
           medication management (Appendix A), based on continuous review and management of blood
           sugars; (2) survival skills diabetes self-management education based on knowledge
           deficits identified on the KNOW Diabetes knowledge survey; (3) enhanced patient-provider
           communication, all provided by Endocrinologist supervised allied health professionals
           (in this instance CDEs).

        -  Survival skills DSME will focus on nutrition and meal plan basics, blood glucose
           targets, taking medications as prescribed, hyper- and hypoglycemia recognition and
           treatment, and when to seek medical help.

        -  The intervention is initiated with one to two face-to-face meetings with the CDE, at
           which the patient's readiness to change is assessed.

        -  These are followed by virtual meetings though a variety of media based on patient
           preference and health literacy (largely telephone and text messaging).

        -  Various technology tools are used to facilitate patient engagement, access and
           attainment of glycemic targets, including smart meters, virtual meeting platforms,
           web-based education content and surveys administration via tablets, etc.

        -  Near real-time transmission of blood glucose data using a cellular-enabled blood glucose
           monitoring system sends all glucose results to a web-based dashboard accessed daily by
           the Boot Camp educators.

        -  Concurrent matched charts of patients receiving standard care at the three MedStar
           locations will serve as a basis of comparison in assessing the impact of MDI on clinical
           and education outcomes and process of care.

        -  Based on patient progress towards improved glycemic control, the patient will 'graduate'
           from the program and the CDE will refer the patient back to their PCP in 8-12 weeks with
           a full report of medication changes, blood glucose readings and further diabetes
           management recommendations eg referrals; further DSME, etc.
    

Intervention name(s): Diabetes Pathway
Intervention type(s): Other
Intervention description(s): Medication algorithm, survival skills education, enhanced patient-provider communication facilitated by near, real-time blood glucose monitoring
Other intervention name(s): Diabetes Boot Camp
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Diabetes Care Management; Chronic Care Model; Resources Utilization; Hemoglobin A1C; Hospitalizations; Emergency Room Visits; Cost analysis; Return on Investment