Nurse-led app intervention to improve glycemic control in patients with insulin-treated type 2 diabetes on Medicaid

Rutgers Biomedical And Health Sciences, Newark NJ

Investigators

Abstract

“Therapeutic inertia,” defined as a lack of timely adjustment to therapy when a patient’s treatment goals are unmet, is a major drive of poor outcomes in type 2 diabetes (T2D). This issue is especially pronounced among individuals enrolled in Medicaid (MA), who face challenges at three levels: patient (e.g., limited resources, low health literacy, and disproportionate access to care), clinician (e.g., lack of time or inadequate cultural sensitiv- ity), and health system (e.g., insufficient decision support or patient panel management). One way to address the complex challenges of chronic disease management is with multi-level health information technology (HIT)- supported behavioral interventions. Such interventions combine changes to clinical workflows and self-man- agement support to help patients track disease electronically, transmit data to clinicians, and receive feedback for adjusting treatment. Currently, minimal data exist to inform optimal design, implementation, and use of such multi-level behavioral interventions for patients with insulin-treated T2D on MA. A multi-level app-based inter- vention may improve outcomes. Work to date has identified the need for greater attention to patient needs; use of insulin; adherence to testing guidelines; and addressing social determinants of health and mental-health concerns. In clinic interviews, health professionals indicated the need for creative visual aids to tailor teaching (e.g., including screenshots of food from patients' local stores); using patients' data as teaching examples; "meeting patients where they are" strategies to help them utilize resources; and tailoring HIT training by patient needs. To facilitate clinician-patient communication, health professionals required clinic support for staff work- flow and customize MyChart message templates by patient needs. This project will develop and pilot-test a nurse-led, app-based behavioral intervention consisting of three evidence-based interventions: (1) education about A1C results and setting goals via MyChart, the patient portal in the Epic electronic health record; (2) a diabetes problem-solving action plan developed by clinicians in collaboration with their patients; and (3) remote monitoring via mySugr, a diabetes app, to analyze blood glucose and identify the need to adjust treatment. The proposed work includes a patient focus group study to help tailor the intervention, and a pilot study at two clin- ics to assess the feasibility of the intervention for patients with insulin-treated T2D. The project will support a future proposal for a pragmatic trial to assess the effectiveness of a multi-level app-based behavioral interven- tion for patients with insulin-treated T2D.