Improving diabetes care of community-dwelling underserved older adults.

BACKGROUND: Diabetes care among rural underserved older adults is negatively affected by social determinants of health (SDOH). Although there is an increased awareness of this problem, evidence-based clinical and community interventions are not widely integrated. This project implemented telemedicine and community health worker (CHW) interventions to improve diabetes management and outcomes. LOCAL PROBLEM: One in five older adults with diabetes mellitus (DM) at a Federally Qualified Health Center in southwest Ohio has uncontrolled disease, largely due to their limited resources and ability to participate in routine clinical management. METHODS: This quality improvement project used a pre-post intervention design. Participants were adults aged ≥65 years with uncontrolled DM type 1 or 2. The outcomes of interest included A1C values, diabetes self-care activities, diabetes knowledge, and patient and health care provider (HCP) satisfaction levels. INTERVENTIONS: The project involved biweekly CHW home visits and diabetes self-management education for 12 weeks. The CHWs, with supervision from a nurse practitioner, conducted SDOH assessments and basic education, and facilitated same-day telemedicine appointments with the HCP to reinforce disease management. RESULTS: The A1C levels and diabetes knowledge of older adults significantly improved after three months. However, there were no statistically significant changes in diabetes self-care activities. The patients and HCPs were highly satisfied with the project interventions. CONCLUSIONS: This project delivered patient-centered and equitable diabetes care services that were previously unavailable to underserved older patients, while demonstrably improving outcomes. Future research should evaluate the cost-effectiveness, long-term impact, and sustainability of the project in other primary care settings.

Motivational interviewing and vaccine acceptance in children: The MOTIVE study.

BACKGROUND AND OBJECTIVE: Vaccine coverage have been less than desired in young children in part due to parental vaccine hesitancy. Addressing health beliefs through patient-centered communication approaches such as motivational interviewing (MI) may improve vaccine confidence. Thus, the objective of this study was to determine the difference in paediatric vaccination coverage rates based on the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) recommended schedule in children 0-6 years of age after an educational intervention for providers and integration of an MI-based communication tool, MOTIVE (MOtivational Interviewing Tool to Improve Vaccine AcceptancE). METHODS: Paediatric and family practice providers in a federally qualified health center in the United States completed an educational intervention regarding vaccine hesitancy and use of the MOTIVE tool. Providers then implemented the MOTIVE tool to address common health beliefs using strong, presumptive vaccine recommendations and an MI framework during encounters with patients 0-6 years of age. Data were collected from 1-year pre-educational intervention (July 2018-June 2019, N = 2504) and post-intervention (July 2019-March 2020, N = 1954) to examine differences in vaccination coverage rates and documented vaccine refusals. RESULTS: Use of the MOTIVE tool was associated with a statistically significant increase in IIV vaccination coverage rate in children 6 months to 6 years of age (32.4% versus 43.9%, p < 0.01). A significantly increased Hib vaccination coverage rate was observed in children 0-18 months of age. Patients with commercial insurance also had significantly higher vaccination coverage rates for the DTaP, IPV, and VAR vaccines during the intervention period. Use of the MOTIVE tool was associated with a decrease in documented vaccine refusals per 100 patients in children 0-6 years of age (31.5 versus 17.6, p < 0.01). CONCLUSION: Use of an MI-based communication tool may decrease vaccine refusals and improve childhood vaccination coverage rates, particularly for IIV. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03934008, https://clinicaltrials.gov/ct2/show/NCT03934008, deidentified individual participant data will not be made available.

Diabetes management among underserved older adults through telemedicine and community health workers.

BACKGROUND: Diabetes mellitus (DM) disproportionately affects older adults from marginalized communities. In the United States, the prevalence of DM in ages ≥65 years is twofold higher than the national average for adult populations. Telemedicine and community health workers (CHWs) are emerging diabetes care models but their impact on older adults with limited resources are relatively neglected within the medical literature. OBJECTIVES: The purpose of this systematic review was to explore the impact of telemedicine and CHW interventions for improving A1C levels and self-management behaviors among underserved older adults with DM. DATA SOURCES: A systematic literature search was performed in PubMed, CINAHL, Embase, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a reporting guideline. CONCLUSIONS: Diabetes self-management education (DSME) administered through telemedicine and CHW interventions were effective for improving A1C levels, self-care adherence, and patient and provider satisfaction among adults aged ≥50 years. Common barriers to diabetes care include inadequate resources, lack of transportation, inconsistent means of communications, social isolation, and low motivation. Community health workers and telemedicine were effective in improving disease management and optimizing care coordination within the vulnerable adult populations. IMPLICATIONS FOR PRACTICE: Well-coordinated, evidence-based, and population-centered interventions can overcome the unique disparities experienced by underserved older adults with diabetes. Incorporating DSME-guided telemedicine and CHW interventions into primary care can mitigate diabetes-related complications in older populations. The lack of evidence specific to adults aged ≥65 years calls for a universally accepted age range when referring to older adults in future research.