Journal Article

Clinic-Based Versus Outsourced Implementation of a Diabetes Health Literacy Intervention

Seligman, Hilary, Davis, Terry C., DeWalt, Darren A., Curtis, Laura M., Schillinger, Dean, Fleming, David A., Parker, Ruth M., Pandit, Anjali U., Wolf, Michael S.

2014

Overview

ABSTRACT BACKGROUND We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. METHODS A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. RESULTS Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm ( p  < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients ( p  < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c ( β  = −0.31, 95 % CI −0.56 to −0.06, p  = 0.02), systolic blood pressure ( β  = −3.65, 95 % CI −6.39 to −0.90, p  = 0.01), and low-density lipoprotein (LDL) cholesterol ( β  = −7.96, 95 % CI −10.08 to −5.83, p  < 0.001) at 6 months. CONCLUSION An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.

• Publisher: Springer US,Springer,Springer Nature B.V
• Subject: Adult / Aged / Ambulatory Care Facilities - organization & administration / Biological and medical sciences / Community Health Centers - organization & administration / Counseling / Delivery of Health Care - organization & administration / Diabetes / Diabetes Mellitus, Type 2 - blood / Diabetes Mellitus, Type 2 - psychology / Diabetes Mellitus, Type 2 - therapy / Diabetes. Impaired glucose tolerance / Endocrine pancreas. Apud cells (diseases) / Endocrinopathies / Etiopathogenesis. Screening. Investigations. Target tissue resistance / Feasibility Studies / Female / General aspects / Glycated Hemoglobin A - metabolism / Health Behavior / Health Knowledge, Attitudes, Practice / Health Literacy / Humans / Internal Medicine / Intervention / Male / Medical sciences / Medicine / Medicine & Public Health / Middle Aged / Missouri / Original Research / Patient education / Patient Satisfaction / Self Care / Self Efficacy / Socioeconomic Factors / Telephone