Measuring the Implementation and Effects of a Coordinated Care Model Featuring Diabetes Self-management Education Within Four Patient-Centered Medical Homes

Purpose The purpose of this study is to measure the implementation and effects of a multisite coordinated care approach that delivered diabetes self-management education (DSME) and diabetes self-management support (DSMS) for disadvantaged patients within 4 patient-centered medical homes (PCMH).

Methods A total of 173 patients (69.9% African American, 26.0% Caucasian, and 4.1% other) experienced elements of the intervention, which featured DSME and coordinated care. Key informant interviews with PCMH site staff were used to capture, code, and characterize activities related to implementation and sustainability of the intervention. Outcome measures collected at baseline and at 6 months included clinical health indicators, A1C, body mass index (BMI), blood pressure, and lipids, as well as the AADE7 Behaviors.

Results A statistically significant decrease occurred in A1C and BMI within 6 months for participants within 1 PCMH. This improvement among clinical health outcomes was associated with the frequency of services provided (eg, DSME, patient support).

Conclusion Integrating and delivering DSME and DSMS within coordinated care settings have the potential to improve PCMH practice and associated clinical health outcomes for populations experiencing health disparities.