Controlling Hypertension in Diabetes- Feasibility Study

Many primary care patients, especially in inner-city settings, do not achieve targets for
blood pressure and glycemic control. There is an urgent need to enhance treatment for those
who do not reach goals within the usual clinical care system. We propose to develop a
multi-component intervention grounded in the Chronic Care Model, and sustainable in
resource-challenged settings. Through collaboration with home health nursing and with the use
of home telemetry for feedback and intensification of therapy, we will augment usual clinical
services to improve health outcomes for diabetes patients who have not been able to reach
therapeutic goals. There are three specific aims. First, we will establish a feasible,
practical and sustainable collaborative model between the primary care sites of our
practice-based research network (NYC RING), clinical researchers at the Diabetes Research and
Training Center, and The Montefiore Home Health Organization, integrating the unique
expertise of each of the partners and defining the roles and responsibilities of each.
Second, we will develop and refine the components of the intervention, to include training
primary care providers and home health nurses to integrate the technical, psychosocial and
communication processes for implementation of the intervention. Third, we will assess the
feasibility of the collaborative intervention by implementing the intervention for 25 primary
care patients and obtain preliminary estimates of effectiveness by comparing outcomes to 25
patients receiving usual care. Our proposal includes plans to develop feasible procedures for
data collection, with qualitative and quantitative methods of assessing process and outcome
measures. We will use these preliminary data to revise the intervention and prepare an R18
application to further develop and test the intervention in multiple inner-city primary care
sites serving low-income diabetes patients. This proposal is for secondary prevention of
diabetes complications, targeting a population known for health disparities and a high burden
from this chronic disease.