Confronting Disparities in Diabetes Care: The Clinical Effectiveness of Redesigning Care Management for Minority Patients in Rural Primary Care Practices

Abstract

: Context: Diabetes mellitus and its complications disproportionately affect minority citizens in rural communities, many of whom have limited access to comprehensive diabetes management services. Purpose: To explore the efficacy of combining care management and interdisciplinary group visits for rural African American patients with diabetes mellitus. Methods: In the intervention practice, an advanced practice nurse visited the practice weekly for 12 months and facilitated diabetes education, patient flow, and management. Patients participated in a 4‐session group visit education/support program led by a nurse, a physician, a pharmacist, and a nutritionist. The control patients in a separate practice received usual care. Findings: Median hemoglobin A1c (HbA1c) was not significantly different at baseline in the intervention and control groups but was significantly different at the end of the 12‐month follow‐up period (P<.05). In the intervention group, median HbA1c at baseline was 8.2 ± 2.6%, and median HbA1c at an average follow‐up of 11.3 months was 7.1 ± 2.3%, (P<.0001). In the control group, median HbA1c increased from 8.3 ± 2.0% to 8.6 ± 2.4% (P<.05) over the same time period. In the intervention group, 61% of patients had a reduction in HbA1c, and the percentage of patients with a HbA1c of less than 7% improved from 32% to 45% (P<.05). Conclusions: These findings suggest that a redesigned care management model that combines nurse‐led case management with structured group education visits can be successfully incorporated into rural primary care practices and can significantly improve glycemic control.

Diabetes Self-Management Interventions for Adults with Type 2 Diabetes Living in Rural Areas: A Systematic Literature Review

“…Five of the 15 studies mentioned a specific behavior theory or conceptual framework to guide their interventions, including health belief model, social cognitive theory, stages of change model, adult learning theory, symptom-focused model, and the chronic care model [27, 23, 24, 32, 34]. Two of these studies, using the chronic care model and a combination of the health belief model with the trans-theoretical model, respectively, demonstrated statistically significant improvements in glycemic control in the intervention arm compared to control [27, 23].…”

“…Two of these studies, using the chronic care model and a combination of the health belief model with the trans-theoretical model, respectively, demonstrated statistically significant improvements in glycemic control in the intervention arm compared to control [27, 23]. Hawkins and colleagues used a combination of social cognitive theory with the trans-theoretical model and motivational interviewing and observed improved glycemic control for both study arms, with specific improvements in self-efficacy in the intervention group [24].…”

Improved Outcomes in Diabetes Care for Rural African Americans

“…This quasi-experimental study assessed the effectiveness of a primary care practice redesign that included a care management intervention, piloted by the investigators, 16 similar to the health-coaching requirements described for patient-centered medical homes. 17 There are 6 key elements to the intervention design: education with behavioral coaching, treatment intensifi cation, point-of-care management, expanded roles of clinic staff to facilitate management, a teamcare approach, and physician leadership.…”

Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis

“…In our synthesis of findings from all 26 studies, we noted reports on aspects of patients' engagement in their health care, including positive outcomes in the domain of selfcare, 2 1 , 2 5 physical activity, 3 9 the setting and achievement of measurable goals, 21,34,39 patient knowledge, 24,31,32,41,44 self-efficacy 23,25 and selfmanagement. 24,26,34,36,40,44 …”