A Comprehensive Community Approach for Diabetes Prevention and Care for a Vulnerable Population in Galveston

Change from baseline weight

measurement of body weight in Kg

Time frame: at 6 months

Change from baseline weight

measurement of body weight in Kg

Time frame: at 12 months

Change from baseline blood pressure

measurement of systolic and diastolic blood pressure in mm Hg

Time frame: at 6 months

Change from baseline blood pressure

measurement of systolic and diastolic blood pressure in mm Hg

Time frame: at 12 months

Change from baseline lipid profile

measurement of lipid profile: Total Cholesterol, Triglycerides, High-Density Lipoprotein, and Low-Density Lipoprotein in mg/dL

Time frame: at 6 months

Change from baseline lipid profile

measurement of lipid profile: Total Cholesterol, Triglycerides, High-Density Lipoprotein, and Low-Density Lipoprotein in mg/dL

Time frame: at 12 months

Change from baseline frequency of provider encounter

Frequency of provider encounter

Time frame: at 6 months

Change from baseline frequency of provider encounter

Frequency of provider encounter

Time frame: at 12 months

Change from baseline frequency of feet examination for neuropathy

Frequency of feet examination for neuropathy

Time frame: at 6 months

Change from baseline frequency of feet examination for neuropathy

Frequency of feet examination for neuropathy

Time frame: at 12 months

Change from baseline frequency of urine exam for microalbuminuria

Frequency of urine exam for microalbuminuria

Time frame: at 6 months

Change from baseline frequency of urine exam for microalbuminuria

Frequency of urine exam for microalbuminuria

Time frame: at 12 months

Change from baseline frequency of oral health checkup

Frequency of oral health checkup

Time frame: at 6 months

Change from baseline frequency of oral health checkup

Frequency of oral health checkup

Time frame: at 12 months

Change from baseline frequency of eye fundus examination

Frequency of eye fundus examination

Time frame: at 6 months

Change from baseline frequency of eye fundus examination

Frequency of eye fundus examination

Time frame: at 12 months

Change from baseline frequency of emergency care visits for treatment of T2-related issues

Frequency of emergency care visits for treatment of T2-related issues

Time frame: at 6 months

Change from baseline frequency of emergency care visits for treatment of T2-related issues

Frequency of emergency care visits for treatment of T2-related issues

Time frame: at 12 months

Change from baseline frequency of hospitalizations and re-admissions

Frequency of hospitalizations and re-admissions

Time frame: at 6 months

Change from baseline frequency of hospitalizations and re-admissions

Frequency of hospitalizations and re-admissions

Time frame: at 12 months

Participation in iDSMES classes (for those in the intervention arm only)

Participation in iDSMES classes (total number of sessions attended)

Time frame: at 12 months

Lifestyle change outcomes (for those in the intervention arm only)

Physical activity minutes in the last week prior to session

Time frame: every session through study completion, an average of 1 year

Change from baseline patient-centeredness

General self-rated Health (GSRH): a single item survey- self-administered single question such as "in general, would you say that your health is? excellent, very good, good, fair, or poor?", where excellent is scored as "5" and poor is scored as "0".

Time frame: at 6 months

Change from baseline patient-centeredness

General self-rated Health (GSRH): a single item survey- self-administered single question such as "in general, would you say that your health is? excellent, very good, good, fair, or poor?", where excellent is scored as "5" and poor is scored as "0".

Time frame: at 12 months

Change from baseline secondary diabetes self-management behaviors

fifty-six-item survey. This includes a series of secondary diabetes self-management behaviors to explore mediating factors that might influence changes in glycemic control. We will assess the proportion of individuals with severe hypoglycemic episodes and use the brief modified Block seven-item diet screener with a four-week time horizon to determine the number of servings per day of fruit and vegetables.

Time frame: at 6 months

Change from baseline secondary diabetes self-management behaviors

fifty-six-item survey. This includes a series of secondary diabetes self-management behaviors to explore mediating factors that might influence changes in glycemic control. We will assess the proportion of individuals with severe hypoglycemic episodes and use the brief modified Block seven-item diet screener with a four-week time horizon to determine the number of servings per day of fruit and vegetables.

Time frame: at 12 months

Change from baseline self-efficacy in managing diabetes

This self-management resource center validated eight-item survey on patient confidence in performing certain activities. The survey is scored from 0 to 10 on a visual analog scale (VAS).

Time frame: at 6 months

Change from baseline self-efficacy in managing diabetes

This self-management resource center validated eight-item survey on patient confidence in performing certain activities. The survey is scored from 0 to 10 on a visual analog scale (VAS).

Time frame: at 12 months

Change from baseline diabetes distress

a two-item screening tool on 17 potential problems in the life of patients with diabetes. Patients are asked to score the distress ensuing from each problem during the last month from 1 to 6, where 1 is "Not a problem" and 6 is "a very serious problem".

Time frame: at 6 months

Change from baseline diabetes distress

a two-item screening tool on 17 potential problems in the life of patients with diabetes. Patients are asked to score the distress ensuing from each problem during the last month from 1 to 6, where 1 is "Not a problem" and 6 is "a very serious problem".

Time frame: at 12 months

Change from baseline medication Adherence

"Morisky Green Levine" Medication Adherence Scale: a four-item tool queries about forgetfulness, carelessness, and feelings around taking medications, scored from 0 to 4.

Time frame: at 6 months

Change from baseline medication Adherence

"Morisky Green Levine" Medication Adherence Scale: a four-item tool queries about forgetfulness, carelessness, and feelings around taking medications, scored from 0 to 4.

Time frame: at 12 months