Primary care provider perceptions of the effectiveness of two self-management support programs for vulnerable patients with diabetes

Abstract

Background: Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs.

Methods: One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering.

Results: Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01).

Conclusions: Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations.

Figure 1

Proportion of primary care providers (n = 87) who perceived self-management support interventions helped overcome barriers to optimal diabetes care for intervention patients (n = 162): comparison between automated telephone self-management and group medical visits.

Figure A1

The automated telephone self-management system. The ATSM system provides weekly calls with rotating queries, in the patient's native language, regarding self-care (e.g., symptoms, medication adherence, diet, physical activity, self-monitoring of blood glucose, smoking); psychosocial issues (e.g., coping, depressive symptoms); and referrals for preventive services (e.g., ophthalmologist). Patients respond via touch-tone commands. Depending on the response to an individual item, patients also receive automated health education messages in the form of narratives. Patients answering “out of range” on ≥1 item, based on predetermined clinical thresholds, receive a call back from a language concordant care manager within 48 h. The care manager helps patients problem-solve around the issue identified in the report, with a focus on collaborative goal setting with action plans. All patient interactions with ATSM care managers, including action plans created and achieved, were communicated with PCPs.

Figure A2

Group medical visit model. A GMV involves language-specific monthly group medical visits for 9 months. Group medical visits involve 6–10 patients, are cofacilitated by a language concordant primary care physician and health educator, last 90 min, and share the same basic structure: (1) group check-in, in which participants report any problems or progress with action plans and the group facilitates problem solving, adjustment, and/or recommitment to action plans; (2) discussion of common concerns or modeling of self-management practices; (3) social break with healthy snacks; (4) short planning session to select subsequent topics; and (5) brief, individualized care to patients with unmet medical needs. All patient interactions with GMV cofacilitators, including action plans created and achieved, were communicated with PCPs.