Objectives: Providers and patients face barriers to accomplishing the complete communication needed to make complex decisions together about diabetes treatments and self-management tasks. Providers often have limited time and patients often have limited resources. Peer mentoring models have been found in two recent VA research trials to be more effective than usual care, financial incentives, and nurse care management in improving glycemic control in high-risk Veteran patients with diabetes. While peers can be trained in effective approaches to support other Veterans' self-management behaviors, such coaches necessarily lack diabetes and diabetes medications content expertise to help Veterans better share in treatment decisions and goal-setting with their health care providers. Accordingly, in a recent research study we developed and tested a tailored, interactive diabetes and diabetes medication information tool that outreach workers can use to facilitate discussions with patients. Such tools can enhance the sustainability and effectiveness of coaching programs to better prepare patients to set self- management goals, action plans, and to discuss treatment options with their providers. Because this intervention addresses barriers to disease management for chronically-ill patients, physicians, and case managers, the study may have broader impact on management practices for other chronic illnesses. Project Methods: 348 diabetes patients with poor glycemic control (A1c>8.0% or A1c>8.5% if older than 70) will be recruited from the Detroit VA and randomized to either Peer Support with TEC or Peer Support alone. All participants will be assigned to one of 87 peer coaches, who also are Detroit VA diabetes patients who previously had poor glycemic control but are currently in good control. Each peer coach will be assigned about 4 participants on the basis of race and approximate age. Peer coaches will undergo training in motivational interviewing-based counseling approaches and instruction in use of the iPad-platform decision aid tool. After their baseline assessment, participants in both arms will receive information on their lab and blood pressure values and will be randomized to one of the two study arms. Participants randomized to the control group will be scheduled for an initial visit wit their coach. The coach will then help them list questions and concerns they wish to discuss with their health care provider, practice raising their questions and concerns and develop an action plan to address barriers to self-management they have identified. Participants in the TEC arm will be scheduled for an initial visit with their coach to review the decision aid, which has incorporated their personal baseline data. The coach will then provide the same intervention that the Control group receives. During the next six months the coach will call their assigned peers once a week to provide support for their action steps. These calls will be placed using a confidential IVR system that connects the callers without sharing phone numbers. The research will measure changes in HbA1c, BP, patient-centered outcomes, mediators and moderators of intervention effects and cost-effectiveness.
Peer support programs have been demonstrated to improve glycemic control among Veterans with poor control. This program will expand on this success by putting innovative tools in the hands of Veteran diabetes patients. Veteran coaches who have demonstrated effective control of their own diabetes will be trained to use communication skills to guide their peers through a diabetes education and decision aid. This tool, which is an iPad application, draws the patient in by showing them their personal risk and medication information derived from baseline labs and self-reported survey data. The tool encourages interaction by providing choices of materials to view, using audio-visual elements and incorporating a goal-setting process for developing self- management action steps and questions to discuss with their doctor at their next clinic visit. Ongoing weekly contact between the Veterans is supported by a confidential phone system.
