Diabetes is a major public health problem that disproportionately affects vulnerable populations, including racial and ethnic minorities, those with lower socioeconomic status and individuals with low health literacy. We propose to evaluate the fidelity of implementation of an innovative health information technology (Health IT) intervention for patients with chronic disease, the Automated Telephone Support Program (ATSM) developed to reach vulnerable populations with diabetes. We have developed and studied ATSM in efficacy and effectiveness trials, finding ATSM is associated with improvements in multiple diabetes-related outcomes. ATSM has received national attention, and is aligned with the national health care reform policy focus on determining how best to deploy health IT to deliver effective health care at low cost to large sectors of the US population. Based on the growing interest, it is critical to examine factors associated with ATSM implementation that may impact its wider adoption. ATSM is a complex intervention that employs phone technology to provide patient surveillance and education and to prioritize further telephone care management efforts for those most in need. ATSM innovation relates to its: (1) integration of electronic information into ongoing clinical care, to improve quality and efficiency of care delivery;and (2) effective health communication tailoring, by care managers over the telephone, for the provision of literacy or language-tailored support counseling. We have provided ATSM in a 'real world'implementation study, with AHRQ funding, in partnership with a regional health plan, the San Francisco Health Plan (SFHP). We propose in this R03 to examine the fidelity of the intervention's implementation and examine adaptations made to increase its adoption. Specifically, we will use a modified Conceptual Framework for Evaluating Implementation Fidelity to organize essential ATSM delivery components. We will use this framework to structure a detailed data-based assessment of fidelity measures (e.g. frequency, content, and duration of ATSM delivery), and measures related to proposed moderating factors to ATSM delivery (e.g. representativeness of participants vs. non- participants, and quality of care management calls). We will work with SFHP to analyze the extensive data collected for the ATSM program, and to develop a User Guide that may inform other organizations considering scaling up similar health IT interventions. There is scant literature on how to adapt complex health IT interventions, such as ATSM, to local health systems needs. Examining the fidelity of implementation of such a program, describing adaptations that were made to improve adoption, and examining how adaptations and moderators will provide relevant necessary information. These findings can move forward the field of diabetes care, provide timely information on processes of adoption critical to implementation planning, and serve as a model for evaluating other complex health IT interventions. This R03 serves as an essential component to developing an evidence base to inform the scaling up health IT innovations such as ATSM.
Diabetes is a major public health problem that disproportionately affects vulnerable populations, including racial and ethnic minorities, those with lower socioeconomic status and individuals with low health literacy. We have developed and found successful in efficacy studies, a health IT innovation that is tailored to patient language and literacy needs, and are completing a study of its effectiveness in a 'real world'translational research trial, with a local Medicaid managed care plan. We propose in this R03 to examine the fidelity of the intervention's implementation and examine adaptations made to increase adoption. This information can inform efforts underway in national health reform, to scale up health IT interventions to off-set growing chronic disease care costs.
