This K23 award will establish the candidate, Dr. Elizabeth Rogers, as an independent physician-investigator with expertise in development, implementation, and evaluation of patient-centered primary care interventions that are strategically designed to address patient complexity ? both medical and social ? to optimize care for low-income patients with multiple chronic diseases. Most of the 29.1 million Americans with type 2 diabetes mellitus (T2DM) have at least one additional chronic condition, but existing management guidelines fail to account for patient complexity. Despite evidence of effective clinic-based interventions, diabetes care quality remains low, particularly in safety net settings serving patients with low incomes, who are disproportionately racial and ethnic minorities, and who carry a larger burden of chronic disease. Until patient complexity factors are meaningfully addressed with specific, pragmatic interventions, patients with comorbid T2DM will remain at risk for poor-quality care. To address this critical need, Dr. Rogers's K23 project will identify key clinic and patient influences on care quality by using a ?cumulative complexity model? as a framework. This model focuses on patients' experiences of (1) ?workload? (disease-specific work such as attending appointments and self-care, plus ?life? demands such as job, family, and transportation) and (2) ?capacity? (e.g. fatigue and physical symptoms, plus factors such as literacy, finances, and social support). The project will be conducted in urban Minnesota clinics that are certified Patient-Centered Medical Homes and part of the Hennepin County Medical Center's safety net care system. After stratifying clinics by diabetes care quality, researchers will administer clinician and staff surveys in 3 high- and 3 low-scoring clinics to identify clinic resources associated with optimal diabetes care quality (Aim 1). They will conduct surveys and in-depth interviews with ?at-risk? patients from these sites to discern their perspectives on social vulnerabilities that impede their engagement in care and specific clinic resources that are helpful in overcoming these obstacles (Aim 2). They will apply these results using the multiphase optimization strategy (MOST, used to design effective and efficient interventions) to develop and pilot test a clinic-based, multi-component behavioral intervention ? one engineered to reduce patient workload, augment patient capacity, and thereby optimize patient-centered care for complex patients with T2DM and depression (Aim 3). A robust training plan, closely aligned with the research plan, will support the development of Dr. Rogers's expertise in patient-centered outcomes research, mixed methodology, and clinic-based intervention development and evaluation. She will be supported by a multidisciplinary team of mentors with expertise in these areas as well as in diabetes, depression, and multimorbidity, and with strong links to community stakeholders. This proposal addresses NIDDK priorities by positioning Dr. Rogers to advance patient-centeredness and improve care quality for patients at risk of experiencing low quality of care, and to test practical and sustainable strategies for improving care delivery and health outcomes in diabetes.
Managing diabetes along with co-occurring chronic conditions is a common problem for low-income patients, many of whom also experience social vulnerabilities. Improving the quality of diabetes care in the clinics serving this patient population requires both clinic- and patient-level initiatives. We will develop and pilot test a multi-component, patient-centered intervention intended to address this complexity in patients with diabetes and depression.