Background
Methods
Study design and setting
MA | CMW | |
---|---|---|
Pre-visit
| ||
Discuss the patient case with the clinician | X | |
Agenda setting with the patient | X | |
Ordering routine services | X | X |
History tracking | X | X |
During the visit
| ||
Document clinician findings | X | |
Send electronic descriptions to pharmacy | X | |
Write prescriptions for the clinician to sign | X | |
Post-visit
| ||
Discuss patients’ concerns | X | X |
Recapitulate the advice given by the clinician | X | X |
Set goals with the patient | X | X |
Make sure that patients can navigate the system | X | X |
Between visits
| ||
Provide culturally appropriate health education and information | X | X |
Assure that people with diabetes receive the services they need | X | X |
Follow up via telephone | X | X |
Offer informal counseling and social support | X | |
Provide information to families to support lifestyle changes | X | |
Build individual and community capacity | X | |
Make home visits to patients | X | |
Reach out into the community of patients | X |
Selection of participants
Ethics statement
Interviews
Data analysis
Results
Key informant role | Intervention (5 clinics) N | Control (7 clinics) N | Total (12 clinics) N |
---|---|---|---|
Practice leader (coordinator, medical director) | 3 | 2 | 5 |
Clinician (physician, nurse practitioner) | 4 | 4 | 8 |
Medical assistant | 3 | 3 | 6 |
Community health worker | 3 | 0 | 3 |
Other (nutritionist and registered nurse) | 0 | 2 | 2 |
13 | 11 | 24 |
Clinic | Setting | Provider organization | Health coach | Team composition | Panel size (Overall diabetics at clinic) | Main patient population | Workflow |
---|---|---|---|---|---|---|---|
1. | Urban | 2 clinics with ~5 clinicians serving low-income families | MA | Team of 2 clinicians and 2 MA | 119 (139) | Latino | MA panel management based on the Teamlet Model1. No home visits. Combining regular MA work with health coaching. MA sees 4 patients per day for health coaching on alternate days. |
2. | Urban | 7 clinics with ~50 clinicians serving low-income families | MA | Team of 6 clinicians and 4 MA. | NS (367) | Recent Chinese immigrants | MA works on weekly rotating schedule as health coach. Sees ~12 patients per day typically in post-visits to clinician. No home visits. |
3. | Small community | 7 clinics with ~40 clinicians serving low-income families. | CHW | Team of 2 clinicians and 1 CHW | 118 (334) | Latino | CHW works mainly office-based via panel management in Teamlet Model. Sees 6-8 patients per day. |
4. | Small community | 2 clinics with ~5 clinicians serving low-income families. | CHW | Team of 3 clinicians and 2 CHW | 137 (143) | Latino | CHW does office-based visits and post-visits based on Teamlet Model. Started small-scale home visits, planning 3-4 joint visits per day by 2 CHW. |
5. | Suburban | 7 clinics with ~40 clinicians serving low-income families. | CHW | Team of 3 clinicians and 1CHW. | 84 (377) | Latino | CHW works community-based with home visits of 25-30 minutes during 4 days per week. One day office-based for follow-up phone calls. Separate from clinic workflow. |
Composite measure* | Intervention mean (Range) | Control mean (Range) | Overall mean (Range) |
---|---|---|---|
Staff relationships | 64.8 (46.9 to 78.2) | 65.7 (56 to 81.7) | 65.2 (46.9 to 81.7) |
Quality improvement | 66.6 (49.4 to 76.5) | 62.7 (49.1 to 76) | 65.2 (49.1 to 76.5) |
Manager readiness for change | 63.8 (42.5 to 77.5) | 63.9 (38 to 80.8) | 63.9 (38 to 80.8) |
Staff readiness for change | 70.0 (60.4 to 81.2) | 67.6 (52.8 to 74.6) | 69.2 (52.8 to 81.3) |
Teamwork attitude | 55.0 (50.0-60.0) | 55.0 (52.5-57.5) | 55.0 (50.0-60.0) |
Clinic workload | 44.9 (33.6 to 60.1) | 41.7 (30.4 to 76) | 43 (30.4 to 60.1) |
Structural capability *
| Intervention (n = 5) | Control (n = 8)† |
---|---|---|
Checklist or flow-sheet for: | ||
HbA1c testing | 4/5 | 6/8 |
Cholesterol testing | 1/5 | 6/8 |
Eye examination | 4/5 | 6/8 |
Nephropathy monitoring | 4/5 | 6/8 |
On-site registry out of target range for: | ||
Laboratory values | 3/5 | 2/8 |
Physical findings (BP, BMI) | 3/5 | 2/8 |
On site registry for patients overdue for: | ||
Screening services | 5/5 | 6/8 |
Diabetes services | 3/5 | 4/8 |
Other chronic disease services | 0/4 | 3/8 |
Shared communication: | ||
HbA1c testing | 2/4 | 2/8 |
Cholesterol testing | 2/4 | 2/8 |
Eye examination | 2/4 | 2/8 |
Nephropathy monitoring | 2/4 | 1/8 |
Health coaching | Practice culture |
---|---|
Flexibility and latitude of health care teams in panel management and home visits | Team composition of dedicated MA/CHW with collaborating clinicians (vs. rotating MA/CHW) |
Cultural adaptation to target population | Care teams supported by practice climates conducive to facilitating the transition of diabetes self-management support responsibilities to CHW/MAs, warm handoff by clinician and acceptance of patients |
Structural capabilities to stimulate monitoring of diabetes care process and outcomes | |
Active support of leadership in MA/CHW health coaching |