Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes.
Date
2022-09
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Abstract
Background
Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging.Objective
To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas.Design
Mixed-methods implementation study.Participants
230 patients with clinic-refractory, uncontrolled T2D.Intervention
ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period.Main measures
Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c).Key results
From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (- 1.43%, 95% CI: - 1.64, - 1.21; P < .001). Benefits persisted at 12 (- 1.26%, 95% CI: - 1.48, - 1.05; P < .001) and 18 months (- 1.08%, 95% CI - 1.35, - 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years.Conclusions
When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population.Type
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Publication Info
Kobe, Elizabeth A, Allison A Lewinski, Amy S Jeffreys, Valerie A Smith, Cynthia J Coffman, Susanne M Danus, Elisabeth Sidoli, Beth D Greck, et al. (2022). Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes. Journal of general internal medicine, 37(12). pp. 3080–3088. 10.1007/s11606-021-07281-8 Retrieved from https://hdl.handle.net/10161/29375.
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Scholars@Duke
Allison A. Lewinski
I am a health services researcher and implementation scientist with a joint appointment at the Duke University School of Nursing (DUSON) and the Durham Veterans Affairs Health Care System (VHA). My expertise spans diabetes distress, qualitative research methods, and virtual care delivery (including telehealth and digital health).
My research examines how virtual care interventions can reduce distress, improve self-management, expand access to evidence-based care, and enhance patient and population health outcomes. I focus on patient-, provider-, and system-level factors that influence the use and effectiveness of virtual care. This work has been funded by competitive grants, published in high-impact journals, presented at national conferences, and used to inform health system decision-making. I am frequently sought by colleagues locally and nationally for expertise in diabetes distress, qualitative methods, and virtual care strategies for grants, projects, and manuscripts.
I strive to improve outcomes for individuals with chronic illness by developing equitable, sustainable virtual care solutions and evaluating their implementation. To optimize these interventions, I apply qualitative and implementation science approaches to ensure alignment among patient needs, care modalities, disease states, and social contexts. My work addresses critical questions: for whom and for what purposes are these interventions effective, in which contexts, and at what points in the care continuum. Ultimately, my research advances the implementation and adoption of virtual care to reduce psychosocial distress and improve health outcomes through patient-clinician interactions and system-level innovations.
Valerie A. Smith
Valerie A. Smith, DrPH, is a Professor in the Duke University Department of Population Health Sciences. Her methodological research interests include methods for semicontinuous and zero-inflated data, cost and utilization modeling, causal inference methods, observational study design, and longitudinal data analysis.
Dr. Smith works largely in collaboration with a multidisciplinary team of researchers, with a focus on health policy interventions, health care utilization and expenditure patterns, program and policy evaluation, bariatric surgery and obesity treatment evaluation, aging, and caregiving.
Areas of expertise: Biostatistics, Health Services Research, Health Economics, and Health Policy
Cynthia Jan Coffman
George Lee Jackson
Areas of expertise: Epidemiology, Health Services Research, and Implementation Science
George L. Jackson, Ph.D., MHA is a healthcare epidemiologist and implementation scientist with a background in health administration. He joined the faculty of the UT Southwestern Medical Center in February of 2023 as a Professor and Director of the Advancing Implementation & Improvement Science Program in the Peter O'Donnell Jr. School of Public Health. He is also currently the initial Interim Chair of the new Department of Health Economics, Systems, and Policy in the O’Donnell School of Public Health. Dr. Jackson has a secondary appointment as a Professor in the UT Southwestern Division of General Internal Medicine and is a member of the Simmons Comprehensive Cancer Center. In addition to his work at UT Southwestern, Dr. Jackson is a Veterans Affairs (VA) Health Systems Research (HSR) Research Health Scientist who works with the VA healthcare systems in both Durham, NC and Dallas, TX. He is the Director of the Implementation and Improvement Science Lab/Core at the Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT). Additionally, he is a co-leader of a cooperative effort between the Dallas VA and Advancing Implementation & Improvement Science Program designed to enhance the infrastructure for partnered health services and other research across the Dallas VA and UT Southwestern focused on enhancing the health and healthcare of Veterans in North Texas and across the Nation.
The UT Southwestern Advancing Implementation & Improvement Science Program seeks to further enhance collaborations between the UT Southwestern and affiliated health systems and community partners in the pursuit of common missions to enhance the health and healthcare of the people of North Texas and beyond. The goal is to develop a system to identify potentially successful projects using implementation and improvement science – which uses rigorous, data-driven research to expand programs and improve a community’s health.
Dr. Jackson’s own research and evaluation efforts focus on the development, testing, and implementation of team-based approaches to address the treatment and prevention of chronic conditions such as diabetes, hypertension, and cancer. He has also evaluated efforts to enhance the organization of mental health care. As an implementation scientist, Dr. Jackson studies strategies focused on the adoption and spread of evidence-informed practices across large health systems. He is currently the corresponding principal investigator for three VA program grants focused on the process of identifying, replicating, and spreading innovations across large healthcare systems. These include the Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) partnered evaluation of the Veterans Health Administration (VHA) Diffusion of Excellence program, Dynamic Diffusion Network (DDN) QUERI Program, and Building and Evaluating the Innovation Infrastructure Across the VA Mid-Atlantic Health Care Learning Network partnered evaluation initiative, all funded by the VA Quality Enhancement Research Initiative (QUERI).
Dr. Jackson received his Doctor of Philosophy (Ph.D.) in epidemiology, Master of Health Administration (MHA), and Bachelor of Science in Public Health (BSPH) in health policy and administration degrees from the School of Public Health at the University of North Carolina at Chapel Hill. He completed an Agency for Healthcare Research and Quality (AHRQ) pre-doctoral fellowship in health services research at the Cecil G. Sheps Center for Health Services Research and AHRQ post-doctoral fellowship in health services research in the Duke Division of General Internal Medicine and Health Services Research & Development (HSR&D) Center at the Durham VA. He came to UT Southwestern from Duke University, where he was a Professor in the Departments of Population Health Sciences, Medicine (Division of General Internal Medicine), and Family Medicine & Community Health. He also co-taught evidence-based practice in the Duke Physician Assistant (PA) Program. Dr. Jackson currently maintains appointments as an Adjunct Professor of Population Health Sciences at Duke and Adjunct Professor of Health Policy and Management at the University of North Carolina at Chapel Hill.
Karen E. Steinhauser
Dr. Steinhauser's primary interests are end-of-life care, medical sociology and patient-provider relationships. Specifically, she investigates the composition and measurement of the quality of life for patients and their families at the end of life. Dr. Steinhauser is a Health Scientist with the Center for Health Services Research in Primary Care, VA Medical Center, Durham; Professor, Department of Population Health Science and Medicine; Senior Fellow with the Duke University Center for Aging; Associate Chief for Research, Duke Palliative Care, and Director, Duke Residency Professional Development Coaching Program.
Karen E. Steinhauser, PhD is a social scientist dedicated to improving quality of life of patients, families, and providers during serious illness. She is a Health Scientist with the Center for Health Services Research in Primary Care, VA Medical Center, Durham and Professor, Department of Medicine, Duke University Medical Center, Senior Fellow with the Duke University Center for Aging, and a former VA Career Development Awardee.
Karen Steinhauser, PhD, is Professor, Departments of Population Health Sciences and Medicine, Duke University Medical Center and Senior Fellow with the Duke University Center for Aging and Health Scientist with the Center for Health Services Research in Primary Care, VA Medical Center, Durham. Her research is dedicated to improving patient and family psychosocial and spiritual care, in serious illness. She has developed measurement tools to assess patient and family quality of life as well as psychosocial interventions to improve the experience of serious illness for patients and those who care for them. Dr. Steinhauser's research has used qualitative and qualitative methods, observational, trial and implementation research. Her latest work includes: developing a measure to assess the spiritual needs in palliative care, and addressing clinician resilience in palliative care. She serves as Associate Chief of Research for Duke Palliative Care, and Director of the Duke Residency Professional Development Coaching program. She has been a long-term member of AAHPM, having served on the research committee and being the 2015 Awardee for Excellence in Scientific Research in Palliative Care. She is the Director of Duke’s Residency Professional Development Coaching Program.
Area of expertise: Palliative Care, Qualitative Research
David Edward Edelman
My general interests are in the improve quality of care for chronic illness, using diabetes as a model. While I have performed research on screening for, diagnosis of, and clinical severity of unrecognized diabetes in patient care settings, my current line of work is in using health systems interventions to prevent cardiovascular disease, and to improve outcomes from comorbid diabetes and hypertension.
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