The Patient-Centered Medical Home and the Chronic Care Model have emerged as complementary frameworks to achieve the Institute of Medicine's goals for high-quality preventive and chronic disease care and to help contain healthcare costs. These models emphasize patient-centered care, including self-management support (SMS), population management, coordinated care teams, improved information systems, and active quality improvement. The effective application of these models in primary care for patients with type 2 diabetes (T2DM) remains a challenge, especially in the key area of SMS. SMS programs are important because they prevent, delay, or reduce over time the complications of T2DM and cardiovascular diseases. Few tools are available to help primary-care clinicians identify, monitor, and intervene on unhealthful lifestyle behaviors and problematic psychosocial factors over time for patients with T2DM. Interactive behavior-change technology can facilitate the adoption of crucial SMS interventions in primary care for patients with T2DM and related health risk behaviors. To be effective, the technology must be well-integrated into the practice system, be cost- and time-efficient, and enhance and complement - but not replace - interactions between patients and primary-care teams. To meet the need for effective SMS intervention, we have developed and tested Connection to Health (CTH), a comprehensive, evidence-based SMS program that uses targeted conversations between primary-care clinicians and patients with T2DM to help improve clinically important diabetes-related health outcomes and resolve self-management problems. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice coaching has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary-care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH for patients with T2DM in diverse primary-care practices, and (b) evaluating the impact of practice coaching to enhance uptake and maintenance of the intervention.
Self-management support involves providing people with the help and resources that they need to take care of their health. This is especially important for patients with diabetes, but it is often hard for physicians and practices to do this well. This project would test different ways of helping primary care practices to do a better job of self-management support for their patients with diabetes.