Managing Diabetes to Gain Opportunities for a More Active Life

Study Overview
=================
Brief Summary
-----------------
The purpose of this novel patient-facing disease management intervention is to develop and test a system embedded within the electronic medical record to engage patients in personalized goal setting and chronic disease management.

Detailed Description
-----------------
The purpose of this novel patient-facing disease management intervention, My Diabetes GOAL, is to develop and test a system embedded within the electronic medical record to engage patients in personalized goal setting and chronic disease management by: 1) establishing personalized goals of care based on comorbidities and preferences, 2) tracking diabetes measures against personalized goals, and 3) selecting the route and intensity of care management to help patients achieve their goals (e.g., telephonic care management, in-person care management, and self-care resources). This application can be used to individualize care, increase engagement with patient portals, and improve patient self-efficacy, as they take a more active role in their care.

Official Title
-----------------
Managing Diabetes to Gain Opportunities for a More Active Life (My Diabetes GOAL)

Conditions
-----------------
Diabetes Mellitus, Type 2

Intervention / Treatment
-----------------
* Behavioral: My Diabetes Goal Survey and Optional Care Management


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: 65 years and older Diagnosis of Type 2 Diabetes Enrolled in MyChart (University of Chicago Patient Portal) Outpatient clinic visit in the prior year Exclusion Criteria: Under 64 years of age No type 2 diabetes Not enrolled in MyChart No outpatient clinic visit in the prior year

Ages Eligible for Study
-----------------
Minimum Age: 65 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>Patients that are enrolled in the intervention arm will receive an email message via MyChart (University of Chicago patient portal) to complete an initial questionnaire. Completion of the questionnaire will be required prior to initiating risk factor tracking and opening the portal to requests for care management support. A study team member (diabetes nurse educator) will contact the patient, if requested via the survey, to initiate telephonic care management or links to additional support services. Upon completion the study, all patients will receive a post-survey via MyChart. | Behavioral: My Diabetes Goal Survey and Optional Care Management<br>* The intervention is already described in the intervention arm description.<br>|
| Active Comparator: Delayed Intervention/Control<br>Patients enrolled in the delayed intervention arm will receive usual care for the first 6 months, and then will receive the survey and intervention as stated above. | Behavioral: My Diabetes Goal Survey and Optional Care Management<br>* The intervention is already described in the intervention arm description.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Documentation of Diabetes Goal | Documentation of a personalized goal for diabetes care (e.g., A1C target) of diabetes care (yes or no). | Baseline, 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Personalized A1C Goals | The A1C goal outcome is based on a survey response and is distinct from the measured A1C from laboratory testing. The number of analyzed A1C goal results is therefore dependent on the number of survey respondents. | Baseline, 6 months | 
| Patient Ability to Reach Personalized Goals | Using EHR data, we will measure whether or not patients are reaching the goals they have documented in the survey. | Baseline, 6 month | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Geriatrics