The vision of the UCSF Collaborative Research Network (CRN) is to contribute to the transformation of primary care through a research agenda that emphasizes innovations in health promotion, preventive health, and chronic illness care. Consistent with the aims of the UCSF Clinical and Translational Sciences Institute (CTSI), the CRN is rapidly expanding its efforts in both effectiveness and implementation research with vulnerable populations. This expansion has intensified engagement of the CRN with the clinicians that serve urban, underserved, vulnerable populations in the Community Health Network of San Francisco, whose catchment area is designated to be a medically underserved area, and the community resources and services oriented to these populations. With support from AHRQ, CRN investigators have recently completed a randomized trial of automated telephone self-management support (ATSM) among English, Spanish, and Chinese speaking patients with poorly controlled diabetes. ATSM employs health IT to promote self-efficacy by assisting patients in developing and maintaining behavioral changes through patient-generated """"""""action plans"""""""". Engagement with ATSM was especially high among participants with communication barriers, such as limited literacy and limited English proficiency, and among Medicaid recipients and the uninsured. Receipt of ATSM was associated with robust improvements in patient-centered dimensions of chronic disease care, including assessment of chronic illness care, interpersonal communication, self-efficacy, and functional status. In addition, ATSM provided a novel, real-time surveillance function for identifying previously undetected potential adverse events and actual adverse events occurring at home, often in the context of patients'self-management of diabetes with regard to medications. Receipt of ATSM, however, was not associated with improvements in either blood pressure or glycemic control. We hypothesize that this lack of benefit with respect to metabolic control can be explained, in part, by the fact that medication intensification/activation was not an explicit goal of the health IT-facilitated ATSM model. The CRN leadership has now aligned its efforts with the San Francisco Health Plan (SFHP), the local nonprofit health plan for Medicaid managed care beneficiaries and a leader in Medicaid managed care innovation. The SFHP Governing Board decided to adopt our ATSM model for its growing number of diabetes patients in the next 12 months, to dedicate staff to respond to ATSM data and engage with enrollees and their providers, and to underwrite the costs of ATSM implementation. As a result, we now have an unprecedented opportunity to further explore the impact of a population-based health IT innovation on key dimensions of chronic disease care quality among vulnerable patients. In this proposal, we have embedded within their larger implementation plan a """"""""practical clinical trial"""""""" with a quasi-experimental design. We intend to: (a) measure the effects of ATSM on patient-centered outcomes among ethnically diverse health plan enrollees with diabetes;(b) explore whether combining ATSM with an additional patient-directed health IT innovation - a medication activation communication strategy triggered by pharmacy claims data - yields differential effects on patient-centered outcomes compared to ATSM alone;(c) quantify and characterize patient safety events identified through active surveillance among ATSM participants and measure differences in the frequency and nature of patient safety events among participants receiving ATSM only versus ATSM plus medication activation;and (d) explore whether either ATSM model is superior to usual care with respect to HEDIS-relevant metabolic and clinical process and outcome measures. This will enable us to examine the effects of ATSM on both patient-centered outcomes and safety through a """"""""real-world"""""""" effectiveness study;measure the incremental benefits of health IT-facilitated medication activation with respect to patient-centeredness, safety, and metabolic outcomes above and beyond health IT-facilitated self-management support;and extend previous collaborations between the CRN and health plans to include translational and implementation research.
