Technology-assisted Case Management in Adults With Type 2 Diabetes (TACM-DM)

• Blood Pressure [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  Blood pressure measurement: Blood pressure readings will be obtained at baseline, 3 and 6 months visits by the RN using automated BP monitors (OMRON IntelliSenseTM HEM-907XL) with the patient seated comfortably for 5 minutes prior to the measurements, following the American Heart Association guidelines. The device will be programmed to take 5 readings at 2 minute intervals, after an initial rest period of 3 minutes.
• Quality of Life [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  Quality of Life: The SF-12 (Ware 1996) is a valid and reliable instrument to measure functional status. It is a widely used brief (1-page, 2-minute) and comprehensive survey that yields summary physical (PCS-12) and mental health (MCS-12) outcome scores that are interchangeable with those from the SF-36 in both general and specific populations. The SF-12 items reproduce at least 90% of the variance in PCS-36 and MCS-36 scores.

The purpose of this study is to help low income patients achieve and maintain better self-management skills and improve blood sugar levels, using a 2-in-1 blood glucose and blood pressure monitoring system and nurse case management. Patients must be served at a Federally Qualified Health Center (FQHC) in coastal South Carolina.

The long-term goal is to develop a practical and sustainable system of diabetes management that will help low income patients achieve and maintain goals within established treatment guidelines regardless of geographic location. This randomized clinical trial will employ the innovative FORA system, an inexpensive, off-the-shelf, state-of-the-art technology comprised of a 2-in-1 Blood Glucose and Blood Pressure monitor, coupled with nurse case management (TACM) to optimize diabetes care for low income, rural adults with type 2 diabetes (T2DM). The target population will be low income patients served in Federally Qualified Health Care Centers (FQHCs) with poorly controlled T2DM residing in coastal South Carolina. Two hundred patients will be randomly assigned to two groups of 100 patients each; Group A (Usual Care) and Group B (Technology-assisted Case Management, TACM). Each patient will be followed for 6 months, with study visits at baseline, 3, and 6 months. The primary outcome will be Hemoglobin A1c (HbA1c) at 6 months post-randomization while the secondary outcomes will be blood pressure control and quality of life (qol) at 6 months post-randomization.

• No Intervention: Usual Care
  Typical office-based practice. In this setting the patient is custodian of his/her own care. Between scheduled visits, the patient is responsible for complying with prescribed treatment including medications, diet and exercise regimen, blood glucose monitoring, and follow up visits. Contact between scheduled visits is patient-initiated and occurs when the patient perceives a problem with the treatment plan. For patients with poorly controlled T2DM, which is often asymptomatic prior to the onset of serious complications, this is a particularly ineffective strategy.
• Active Comparator: Technology-assisted Case Management (TACM)
  This model capitalizes on information technology like the FORA system to link a case manager to poorly controlled diabetics in real time. Clearly a model that is applicable only to patients in need of intensive intervention, the advantages includes accurate data transfer to a medical decision maker and positive reinforcement/feedback to the patient via the FORA system to enhance adherence. If the case manager has physician-supervised prescriptive authority, then medication adjustments can be made daily or weekly, if needed, to achieve and maintain control. More frequent interventions, combined with improved compliance with medications and testing frequency, the strategies that are known to work, are enabled by this approach.
  Intervention: Device: Technology-Assisted Case Management (TACM with the FORA 2-in-1 Telehealth System)

Inclusion Criteria:

• Age ≥18 years and receiving care within the Franklin C. Fetter Family Health Center
• Clinical diagnosis of T2DM and HbA1c ≥8% at the screening visit
• Subject must be willing to use the FORA 2-in-1 system
• Subject must have a working land-line for the duration of the study in order to be able to upload the readings from the FORA 2-in-1 machine
• Subjects must be able to communicate in English

Exclusion Criteria:

• Mental confusion on interview suggesting significant dementia
• Participation in other diabetes clinical trials
• Alcohol or drug abuse/dependency using a screening questionnaire
• Active psychosis or acute mental disorder
• Life expectancy <6 months
• Pregnant and/or lactating females