We will test the effectiveness and fidelity of embedding the American College of Physicians (ACP) diabetes health literacy intervention among patient-centered medical homes throughout rural Arkansas. Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that have been designed for individuals with lower literacy skills, that can be readily implemented and sustained among rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy ACP intervention promoting diabetes self-care that includes: 1) a diabetes guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change (`action plans'); 3) a training module for providers (physicians, nurses, medical assistants) that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool; 4) electronic tracking and monitoring tools for primary care practices. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, it has not yet been comprehensively tested in practices, and its optimal implementation is not known. We now have a unique opportunity to learn from our prior evaluation, modify and disseminate an ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices are embedding care coordination services that can be leveraged to improve chronic disease management. All are supervised by a new University of Arkansas for Medical Sciences (UAMS) Center for Health Literacy. Our revised intervention will blend outsourced and clinic-based approaches and redeploy health coaches for counseling self-management mostly via phone, but also at the point-of-care. This is a feasible way to reach rural, vulnerable patients. We will conduct a patient-randomized, pragmatic clinical trial among 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes. Our primary aims are to: 1) test the effectiveness of the ACP diabetes health literacy intervention to improve a range of diabetes-related outcomes among rural patients; 2) compared to usual care, evaluate whether the intervention reduces disparities by patient literacy level. Our secondary aims are to: 3) investigate whether a threshold or gradient effect exists between the amount of follow-up counseling (number of action plans) and intervention effectiveness; 4) determine the fidelity of all intervention components, and explore any identified patient, provider (physician, nurse, health coach), and/or health system barriers to implementation; and 5) assess the costs associated with implementing the intervention from a health system perspective.

Public Health Relevance

This study aims to determine the best way to deliver diabetes care, education, and coaching to patients in rural areas so that patients at primary care clinics can be healthier and have fewer health problems resulting from diabetes. We will test two different ways to help patients through counseling, coaching, and written materials.

National Institute of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Thornton, Pamela L
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University of Arkansas for Medical Sciences
Schools of Medicine
Little Rock
United States
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Hadden, Kristie B; Arnold, Connie L; Curtis, Laura M et al. (2018) Rationale and development of a randomized pragmatic trial to improve diabetes outcomes in patient-centered medical homes serving rural patients. Contemp Clin Trials 73:152-157