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).
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
58
The following information will be collected: demographics, literacy screener, depression screener, medication adherence, self-efficacy, tobacco use, patient activation, health questionnaire, eating patterns, diabetes self-management assessment, stages of change questionnaire, vitals, and self-care behaviors.
A nurse will contact patients by phone at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.
The Regional Medical Center of Orangeburg and Calhoun Counties
Orangeburg, South Carolina, United States
Change of Number of Hospital Re-admissions from 2 Years Prior to Study Enrollment to 1 Year After Study Completion
Hospital data will be obtained from Revenue and Financial Affairs South Carolina Data Oversight Council. These data come from the health organization where patients receive care and include components such as age, health care facility type, dates of admission/ discharge, length of stay, charges, payment source, primary and secondary procedure codes.
Time frame: Retrospective billing collection 2 years prior to study enrollment and 1 year after study completion
Change of Self-management Success Measured by Diabetes Self-Management Assessment Survey Tool from Baseline to Study Completion
Diabetes self-management assessment tool administered to participant over the phone or in-person
Time frame: Baseline, 1 month post-enrollment, 2 months post-enrollment, 3 months post-enrollment (study completion)
Change of Health Goal Progress Captured by Field Notes to Track Intervention Activities from Baseline to Study Completion
Field Notes are completed after each interventionist's interaction with the participant to track progress to addressing health goals
Time frame: Baseline, 1 month post-enrollment, 2 months post-enrollment, 3 months post-enrollment (study completion)
Change of Diet Measured By a 24-item Introduction to the Lifestyle Survey from Baseline to Study Completion
The 24-item Introduction to the Lifestyle Survey will be used to assess diet (fats, protein, fruits and vegetables) and at enrollment, week 4 and 12
Time frame: Baseline, 1 month post-enrollment, 2 months post-enrollment, 3 months post-enrollment (study completion)
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An in-person Community Health Worker will contact patients in-person at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.