1 Despite the high importance patients place on the role of cost in their care, evidence-based, scalable 2 interventions are needed to address prevalent health-related financial burdens and unmet social determinants 3 of health (SDHs) that impair the ability of adults with uncontrolled diabetes to adhere to effectively manage 4 their condition. Solutions need to optimize the time of busy providers and overburdened delivery systems to 5 address complex patient needs. The long-term goal of this research is to improve health behaviors and 6 outcomes by better engaging patients in care, and to develop effective mechanisms that identify and address 7 their unmet SDHs and health-related financial burdens that contribute to adverse health outcomes. In this 8 study, we will refine and test the effectiveness of Care$olutions-- an automated e-health tool for tailored 9 screening of health-related financial burdens and unmet SDHs that informs and activate patients with 10 uncontrolled diabetes to take steps in accessing resources and engaging in self-care. Our central hypothesis is 11 that activating patients with uncontrolled diabetes and linking them to resources to address financial burden 12 and unmet SDHs will improve both intermediate outcomes and measures of disease control (e.g., HbA1c) 13 above and beyond existing services, especially for high need patients. Guided by strong preliminary data, this 14 hypothesis will be tested by pursuing two specific aims: 1) Determine the effectiveness of Care$olutions 15 relative to existing services in order to improve glycemic control and patient-centered outcomes such as cost- 16 related non-adherence (CRN) behaviors and perceived financial burdens; and 2) use quantitative methods to 17 examine the role of patient risk factors (moderators) and behavioral factors (e.g. uptake and use of resources) 18 (mediators) on the effectiveness of Care$olutions in improving outcomes. We will use user-centered design to 19 ensure that features of Care$olutions provide long-term sustainability. 720 patients with uncontrolled diabetes 20 (type 1 and type 2) who engage in CRN or perceive financial burden will be recruited from the University of 21 Michigan Diabetes Registry and randomized to receive a 15-20 minute web-based program with routine follow- 22 up (Care$olutions), versus contact information for existing assistance services in the health system. Outcomes 23 will be assessed at baseline and 6- and 12-month follow-up via survey data (validated with health records), and 24 HbA1c assessments. The proposed research is innovative because it provides a comprehensive, low-literacy 25 e-health tool to guide patients through identification of health-related financial burdens and unmet SDHs that 26 impact disease management, links them directly to resources, and provides training to address needs with 27 providers. It addresses a significant gap in care by evaluating an approach to addressing patient needs that 28 optimizes their health and the time of providers. The proposed research is significant because it is expected 29 yield an evidence-based scalable method to address resource needs of socioeconomically-vulnerable 30 populations to improve treatment adherence, reduce health disparities, and diabetes complications.
The proposed research is relevant to public health because in order to address NIH's mission to improve the outcomes of complex patients and reduce health disparities, health care delivery needs to better address the social determinants of health. An evidence-based, time-optimizing intervention that addresses resource needs and improves treatment adherence in socioeconomically-vulnerable populations has broad translational importance in an era where delivery systems must re-orient to value-based reimbursement models.
