Pilot of Home Visitation Services for Patients With a Diabetes Diagnosis

Summary

This pilot program will assess whether an enhanced PCMH model with more intensive management and intervention can improve chronic disease patient outcomes, improve healthcare delivery, and reduce healthcare costs. Participants in this program are current patients at Leland Medical Clinic and are either enrolled, or eligible to enroll, in Mississippi's Medicaid program. This pilot program will test the effectiveness of high-quality interventions comprising of: (1) an educational intervention focusing on chronic disease management and (2) home visits by a trained community outreach worker.

This pilot program will evaluate both process measures and outcome measures. Examples of process measures include, but are not limited to, the number of patients enrolled in each intervention group, the number of educational classes attended by a unique patient, and the number of home visits a unique patient receives. Examples of outcomes measures include, but are not limited to, change in patient HbA1C levels, change in patient LDL/HDL levels, change in patient blood pressure (systolic and diastolic) levels, and a comparison of patient cost data (total expenditure, expenditures by other major categories like hospital, pharmacy, etc.) After baseline measurements, patient clinical values will be acquired every 3 months for the duration of their engagement.

This pilot project has three specific goals:

Goal 1: Improve healthcare delivery for chronic disease patients enrolled in Mississippi Medicaid.

Goal 2: Improve clinical outcomes for chronic disease patients enrolled in Mississippi Medicaid.

Goal 3: Reduce Mississippi Medicaid costs for chronic disease patients enrolled in this pilot program.

Conditions

• Diabetes

Interventions

BEHAVIORAL

Home Visitiation

The home visit component of the intervention will involve a visit to participants' homes by a social worker, who will assist patients dealing with other health and social problems. Participants will be followed for a minimum of 10 weeks, and additional follow-up visits will be at the discretion of the social worker. They will work with community partners and refer patients when appropriate. Community partners could include: Domestic violence services, employment placement, benefit enrollment, community action agency (bill pay, utilities), ACA enrollment, homeless shelter, housing authority, re-housing program

BEHAVIORAL

Education

The education component of the intervention will include attending a class once per week for 3 weeks. Classes will be led by a dietician, and may also involve other members of an interdisciplinary team including nurse practitioners, health educators, and community members. Education sessions will be held at 5:30pm on Mondays or Tuesdays, and participants will be provided with a meal. Topics will include: * Week 1 (5:30-6:30pm): Importance of self-management of disease, glucometer testing for blood sugars and using home blood pressure monitors, diabetes medication review * Week 2 (5:30-7:00pm): Diabetes and Healthy Eating and Exercise - carbohydrate counting, portion control, lifestyle activity, and exercise demonstration activity * Week 3 (5:30-6:30pm): Grocery shopping guidelines, label reading, hands on cooking demo

Sponsors & Collaborators

• University of Tennessee

  collaborator OTHER

• Emory University

  collaborator OTHER

• Delta Health Alliance

  lead OTHER

Principal Investigators

• Karen C Matthews · Delta Health Alliance

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2018-01-01

Primary Completion

2022-12-31

Completion

2022-12-31

Countries

• United States

Study Locations