FL3X-GRAD Integration
Creators: name: Sehgal, Abhinav
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2018

description: Self-management of type 1 diabetes mellitus (T1D) is critical in glycemic control and morbidity risk reduction. It is especially challenging for adolescents with T1D to adhere to the meticulous routine necessary for optimal hemoglobin A1C (HbA1C) level management. FL3X is a program with strict eligibility criteria that employs adaptive behavioral intervention to improve HbA1c in adolescents with T1D. The utilization of motivation interviewing (MI), problem-solving skills training, and Behavioral Family System Therapy in the FL3X Intervention may improve T1D associated outcomes in participants. However, to successfully employ the methods of FL3X to optimize T1D management in other adolescent populations, the intervention must be integrated into T1D clinical practices. An existing T1D-care program is the Get Real About Diabetes (GRAD) program in the Greenville Health System (GHS). Like FL3X, GRAD employs MI in T1D counseling to help adolescents (recruited for having poor glycemic control according to their providers in GHS) better manage their T1D. GRAD was temporarily interrupted due to staffing changes, and the initial implementation and ongoing practice of GRAD are referred to as GRAD 1 & GRAD 2, respectively. Therefore, the goals of this FL3X-GRAD Integration study were to evaluate GRAD 1 and GRAD 2, compare the program design and delivery of FL3X and GRAD, and determine how the FL3X intervention may be feasibly implemented into the GRAD practice. To evaluate GRAD, demographic, attendance/participation, and clinical data were collected from GRAD 1 (N=77), GRAD 2 (N=37), and non-GRAD (N=68), the control group from GHS. Differences in demographic, attendance/participation, and clinical data were non-significant between GRAD 1 and GRAD 2. Furthermore, neither GRAD program showed significant benefit in improving in glycemic control compared to non-GRAD (P=0.2927). With respect to recruitment, the demographics of GRAD participants were similar to that of non-GRAD patients and the baseline glycemic control in GRAD was significantly poorer than in non-GRAD; however, subgroup analyses showed significantly poorer glycemic control in females, individuals less than 13 years of age, and non-Hispanic, white youth in GRAD, while differences in baseline HbA1c of other GRAD subgroups within the same sex, age, and race & ethnic categories were nonsignificant with respect to the same subgroups in non-GRAD. The evaluation and comparison of program design and delivery of GRAD 1 and 2 suggest that the staffing changes did not affect program delivery or participant outcomes significantly. Overall, the GRAD program shows no efficacy in improving glycemic control of participants. With respect to demographics, GRAD participants are generally reflective of the T1D youth in GHS; however, subgroup analyses suggest inadequate opportunity for referral/recruitment into GRAD of males, individuals older than 13 years of age, and minority youth from GHS. To inform the design and logistics of the clinical integration of FL3X, key informant interviews were conducted with available members of the GRAD staff (N=4). Responses indicated high-buy-in from staff and projected high-buy in from GRAD participants for integration of FL3X, concerns for financial, space, time, and personnel constraints that would be introduced by FL3X, preference for the current social worker and CDE to be FL3X coach, and preference for the FL3X coaching visit to be within the office visit. As such, a FL3X With Office Visit Model of clinical integration was selected as it follows the defined program design and delivery approaches of FL3X, while introducing the least constraints and including the FL3X coaching visit within the office visit. Thus, the FL3X With Office Visit Model is hypothesized to best integrate with the T1D care of youth in GHS and improve intervention recruitment and delivery with respect to GRAD.