Trial Outcomes & Findings for Embedded Primary Care MultiDisciplinary Diabetes Clinic (NCT NCT06015685)

The study included a patient intervention and a resident educational curriculum; however, only patients with diabetes were enrolled and included in the clinical trial results reported in this record. Participants were recruited from the Emory Primary Care Clinic at Midtown in Atlanta, Georgia, USA. Participant enrollment began on October 20, 2023, and all follow-up was completed by January 24, 2025.

Residents participated in a 12-month educational curriculum as part of their routine training. They were not consented, no participant-level data were collected, and they were not formally enrolled as study participants. Therefore, they do not constitute an Arm/Group for results reporting. All reported Participant Flow and outcomes (e.g., HbA1c, diabetes management self-efficacy scores) apply only to enrolled participants (patients) with diabetes.

Embedded Primary Care MultiDisciplinary Diabetes Clinic

Participants with HbA1c \>9% since the embedded clinic implementation. Data will be assessed from electronic medical records (EMR)

HbA1C results from electronic medical records.

Participants will complete the Diabetes Management Self-Efficacy Scale (DMSES). It assesses the extent to which respondents are confident in their ability to manage their blood sugar, diet, and exercise level. Responses are rated on a 5-point scale ranging from ''can't do at all'' (1) to ''certain can do'' (5). A sum of scores is calculated. On this scale, higher scores in each domain indicate greater self-efficacy in performing Diabetes self-management (DSM) activities, while lower scores indicate specific areas needing educational intervention. Score ranges: Domain 1 Nutrition: 9-45 Domain 2 Treatment: 3-15 Domain 3 Physical Activity: 4-20 Domain 4 Monitoring: 4-20 Overall higher scores indicate a greater self-efficacy (better outcome).

Depression will be assessed using the 9-question Patient Health Questionnaire (PHQ9), which is a diagnostic tool to screen adult patients in a primary care setting for the presence and severity of depression. Scores represent: 0-5 = mild 6-10 = moderate 11-15 = moderately severe. 16-20 = severe depression.

Generalized Anxiety Disorder 7 (GAD-7) is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder. Questions reflect on symptoms over the past two weeks. Scoring: Items are rated on a scale from 0 ("not at all") to 3 ("nearly every day"), with total scores ranging from 0 to 21. Scores represent 0-4: Minimal Anxiety; 5-9: Mild Anxiety; 10-14: Moderate Anxiety; a score greater than 15: Severe Anxiety

To measure food insecurity, participants will complete the Latin American and Caribbean (ELSCA) Household Food Security Measurement Scale. This scale uses a set of 15 questions, with yes/no response categories, seven of which are for households with children. Each question asks the respondent whether he/she or any other household member has experienced a certain manifestation of food insecurity in the previous three months. Households that affirm 3 items are classified as food insecure.

Change in urine microalbumin (mcg/mg min 0 and higher the worse the outcome) will be calculated from available laboratory assessments from EMR

Percentage of participants of being at risk for housing insecurity by answering the 2-question housing insecurity instrument: (1) "Are you worried or concerned that in the next 2 months you may not have stable housing that you own, rent, or stay in as part of a household?" with responses of "yes" or "no," and (2) "How likely do you think it would be that you would have to use a homeless shelter in the next 6 months?" with 4 response options ranging from "very unlikely" to "very likely."