Diabetes Interprofessional Team to Enhance Adherence to Medical Care

AAs have twice the rate of DM as Whites, and worse glycemic control, less optimal medication
regimens, and less trust in the medical system. These disparities contribute to why AAs with
DM are more likely to go blind, lose limbs, require dialysis, develop dementia, and die than
Whites. These disparities, in turn, reflect racial differences in education, income, health
literacy, cultural beliefs, experiences of discrimination, and social adversity, which can
lead to: 1) poor glycemic control; 2) suboptimal medication use; and 3) mistrust in medical
care. DM I-TEAM addresses these 3 factors, which often precipitate ED and hospital care,
using a culturally relevant, multidisciplinary team treatment approach to reduce the need for
high acuity medical care, and equip underserved AAs with DM with the knowledge and skill to
gain the benefits of high quality medical care that is otherwise available to everyone. Our
approach applies currently available treatment elements in a culturally-relevant way to
create a more equitable health landscape. Our immediate goal is to engage a high-risk
population in treatment that can be trusted; that recognizes the realities of their lives
(e.g., financial insecurity); that improves the quality of the medication they take, and that
builds their self-efficacy to manage DM. The intermediate goal is to prevent untoward medical
events that necessitate ED or hospital care. The long-term goal is to reverse the pernicious
racial disparities that now characterize healthcare in the U.S. DM I-TEAM can achieve these
goals by getting the right care to the right patient at the right time. DM I-TEAM is the
right care because its leverages existing resources in a new way to improve health outcomes
in AAs with DM. AAs with DM are the right patients because many have poorly controlled DM,
take suboptimal medications, and face treatment barriers, often social in nature. Now is the
right time, as the population becomes more racially diverse, healthcare costs increase, and
demand for safety, quality, and value intensify. In these ways DM I-TEAM is right for
American healthcare, bringing us closer to Healthy People 2020's twin goals of reducing the
personal and societal costs of DM, and achieving health equity for all.

DM I-TEAM takes a dynamic team approach to diabetes management whereby the primary care
physician, the study pharmacist, the diabetes educator, and the CHW collaborate to build
patient trust, encourage diabetes self-management, and optimize medication regimens. Each
member of the team plays a pivotal role in identifying important information that prevents
effective diabetes management, and then works together to provide multi-layered support to
patients. The roles of each team member are as follows:

CHW: The CHW extends clinic-based care into participants' homes to strengthen
patient/provider relationships, customize diabetes education, and develop tailored treatment
plans. The CHW facilitates telemedicine visits with the PCP and diabetes educator to build
trust in the health care system by increasing participants' access to their care team. The
quality and content of these visits is enhanced by CHW-provided information about the
participant's life situation (e.g., family circumstances, barriers to optimal diabetes
self-management, home environment), and current self-management practices and beliefs. There
will be 6 90 minute in-home CHW sessions within 3 months of randomization (telemedicine
sessions will occur during 3 of these visits). Booster sessions will occur 5, 7, and 11
months after randomization. During these visits, the CHW will (1) reinforce the diabetes
treatment plan articulated by the PCP, (2) gather information regarding barriers to diabetes
self-management behaviors and communicate them to the team; (3) inform the team of the
participant's health-related questions/issues; (4) provide culturally-relevant diabetes
education using appropriate educational materials; (5) work with the participant to formulate
and execute diabetes Action Plans using the principles of Behavioral Activation (BA); and (6)
communicate the participant's progress with their Action Plans to the team. BA is a
behavioral technique based on reinforcement theory that is used to help people overcome
avoidant tendencies through goal setting, activity scheduling, and graded task assignment. BA
was originally developed to treat depression. Our research has demonstrated that BA can
successfully facilitate diabetes self-management. The DM I-TEAM treatment manual (which is
already developed but will be refined during the study start-up phase) describes each session
in detail, and includes scripts and didactics for the CHW interventionist. The manual is not
included in this grant submission due to space limitations. At each session, the CHW educates
participants to contact the ED (either by phone or by patient portal) prior to presenting for
services. Participants are given "emergency kits" that contain glucometers and related
supplies and glucose tablets. The ED physician may recommend that participant's test their
glucose and treat hypoglycemia prior to or instead of reporting to the ED.

PCP: The PCP provides diabetes care as per standard practice, but care is supplemented with
input from the pharmacist and the CHW, and with telemedicine visits. The PCP optimizes
medication regimens based on pharmacist recommendations. As the course of treatment
progresses, the PCP reinforces Action Plans with the participant during clinic visits.

Pharmacist: With information gathered by the CHW and from the participant's electronic
medical records (EMR), the pharmacist performs a comprehensive evaluation of the
participant's medications to identify medications that are contraindicated in older patients,
are not being taken as prescribed, are being taken incorrectly, are improperly dosed, or may
be causing undesirable side effects. Based on her assessment, the pharmacist may recommend
that the PCP modify the current medication regimen.

Diabetes Educator: The diabetes educator provides telemedicine visits to supplement diabetes
education provided by the CHW, answer participants' questions, and reinforce medication
adherence.

Inclusion Criteria:

1. African American race

2. Age ≥ 60 years

3. Type 1 or 2 DM

4. A DM-related cause for the ED visit (i.e., hyperglycemia/hypoglycemia, diabetic
ketoacidosis, chest pain, skin or soft tissue infection, diabetic neuropathy,
retinopathy, urinary tract infection/pyelonephritis/acute renal injury, requesting DM
medication refill) OR an hemoglobin A1c of 7.0% or greater within the past 30 days

Exclusion Criteria:

1. Evidence of cognitive and functional decline suggestive of dementia.

2. Anti-dementia medication use

3. Life expectancy less than one year (in the opinion of the evaluating ED physician)

4. DSM-V psychiatric disorders other than anxiety or depression (as per EMR)

5. Intoxicated

6. Suicidal

7. In police custody or currently incarcerated

8. Undergoing medical clearance for a detox center or any involuntary court or magistrate
order

9. Lives in assisted living, currently in a rehabilitation facility (other than
Jefferson), lives in a nursing home or skilled nursing facility