Bamberg Diabetes Transitional Care Pilot Study

Medical University of South Carolina (MUSC)

Status: Completed

Conditions: Diabetes

Treatments: Behavioral: In-person Community Health Worker; Behavioral: Telephonic Nurse Intervention; Behavioral: Surveys

Study type: Interventional

Funder types: Other

Identifiers

NCT02560090

Pro00038334

Details and patient eligibility

About

Bamberg County residents who has been diagnosed with or is at high risk for diabetes, may be eligible for a clinical research study to improve diabetes self-management and decrease hospital re-admissions.

The purpose of this study is to compare the effectiveness of three hospital discharge follow-up methods:

1. standard of care,
2. a nurse telephone intervention (care coordination and education), and
3. an in-home community health worker intervention (care coordination and education).

Enrollment: 58 patients

Sex: All

Ages: 18 to 75 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Bamberg County resident
• between 18 and 75 years of age
• a patient discharged from the Regional Medical Center emergency department or Regional Medical Center hospital within 72 hours prior to consent
• diagnosed with diabetes or at high risk for diabetes
• will be a Regional Medical Center patient for follow-up care
• speaks English
• has access to a phone

Stage 2 Recruitment:

• If recruitment at 3 weeks after the first patient is enrolled is < 15 or the recruitment at 12 weeks is < 45, additional inclusion criteria will include the following: Regional Medical Center outpatient or unassigned community member with uncontrolled diabetes (defined as A1C >8 or blood pressure >140/90) is uninsured or who self-reports problems with obtaining medications.

Exclusion criteria

• end-stage renal disease
• terminal illness (e.g., advanced cancer, end-stage chronic obstructive pulmonary disease, advanced dementia)
• incarceration
• resident in a skilled nursing home.

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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58 participants in 3 patient groups, including a placebo group

Control Group

Placebo Comparator group

Description:

Survey assessments as well as collection of medical records and billing information.

Treatment:

Behavioral: Surveys

Telephonic Nurse Intervention

Active Comparator group

Description:

Survey assessments as well as collection of medical records and billing information. A nurse will communicate with participants via telephone to support diabetes self-management practices.

Treatment:

Behavioral: Surveys

Behavioral: Telephonic Nurse Intervention

In-person Community Health Worker Intervention

Active Comparator group

Description:

Survey assessments as well as collection of medical records and billing information. A community health worker will work with participants in person to support diabetes self-management practices.

Treatment:

Behavioral: Surveys

Behavioral: In-person Community Health Worker