Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience" Making sense of change: patients' views of diabetes and GP-led integrated diabetes care. Improving Chronic Care of Type 2 Diabetes Using Teams of Interprofessional Learners The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial The North Dublin randomized controlled trial of structured diabetes shared care. Effectiveness of nurse practitioner coordinated team group visits for type 2 diabetes in medically underserved Appalachia The effect of an education programme (MEDIAS 2 ICT) involving intensive insulin treatment for people with type 2 diabetes. Shared care with task delegation to nurses for type 2 diabetes: prospective observational study. Integrated care for diabetes: clinical, psychosocial, and economic evaluation Integrating Type 2 Diabetes Mellitus and Depression Treatment Among African Americans Improvements in patient-reported outcomes associated with an intervention to enhance quality of care for rural patients with type 2 diabetes: results of a controlled trial. 3-Year Follow-up of Clinical and Behavioral Improvements Following a Multifaceted Diabetes Care Intervention Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes. Integrated Management of Type 2 Diabetes Mellitus and Depression Treatment to Improve Medication Adherence: A Randomized Controlled Trial Movement as Medicine for Type 2 Diabetes: protocol for an open pilot study and external pilot clustered randomised controlled trial to assess acceptability, feasibility and fidelity of a multifaceted behavioural intervention targeting physical activity in primary care Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial
PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level Background Most research publications on Chronic Care Model ( CCM ) implementation originate from organizations or countries with a well-structured primary health care system . Information about efforts made in countries with a less well-organized primary health care system is scarce . In 2003 , the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting , a setting where the organisational framework for chronic care is mainly hospital-centered . Methods Process evaluation of an action research project ( 2003–2007 ) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients . In consultation with the region a program for type 2 diabetes patients was developed . The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey ( ACIC ) . A multi method approach was used to evaluate the implementation process . The result ing data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process . Results The overall ACIC score improved from 1.45 ( limited support ) at the start of the study to 5.5 ( basic support ) at the end of the study . The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care . The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator . Important barriers were the complexity of the intervention , the lack of quality data , inadequate information technology support , the lack of commitment procedures and the uncertainty about sustainable funding . Conclusion Guided by the CCM , this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure . The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers . Currently primary care providers lack the opportunities to take up full responsibility for chronic care . Trial registration number Clinical Trials.gov Identifier : BACKGROUND Health system reform is directed towards better management of diabetes . However , change can be difficult , and patients ' perspectives are a key aspect of implementing change . OBJECTIVE This study investigated patients ' perceptions and experiences  of  type 2 diabetes ( T2DM )  , self-care and engagement with GP-led integrated diabetes care . DESIGN Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care .  Normalization process theory was used to orientate the thematic analysis , to explain the work of implementing change . SETTING Two specialist GP-based complex diabetes services in primary care in Brisbane , Australia . PARTICIPANTS Intervention group patients ( n = 30 ) in a r and omized controlled trial to evaluate a model of GP-led integrated care for complex T2DM . MAIN OUTCOME MEASURES Participants ' experiences and perceptions of diabetes management and a GP-led model  of care . RESULTS Three themes were identified : sensibility of change , ' diabetic life ' and diabetes care alliance . The imperative of change made sense , but some participants experienced dissonance between this rational view and their lived reality . Diabetes invaded life , revealing incongruities between participants ' values and living with diabetes . They appreciated a flexible and personalized approach to care . DISCUSSION Participants responded to advice in ways that seemed rational within the complexities of their life context . Their diabetes partnerships with health professionals coupled providers ' biomedical expertise with patients ' context ual expertise . CONCLUSIONS Learning to manage relationships with various health professionals adds to patients ' diabetes-related work . Providers need to adopt a flexible , interactive approach and foster trust , to enable better diabetes care Purpose To improve the care and outcomes of adult patients with type 2 diabetes by teaching interprofessional teams of learners the principles and practice s of the Improving Chronic Illness Care Model . Method The study population consisted of 384 adult patients with type 2 diabetes . The study design was a nonr and omized , parallel-group , clinical trial conducted during 18 months in the University of California , San Francisco internal medicine clinics .  Interprofessional team care provided by primary care internal medicine residents , nurse practitioner students , and pharmacy students was compared with usual care by internal medicine residents only .  Processes of care , clinical status , and health utilization were measured in both patient groups . Learner outcomes also were assessed and compared . Results At study completion , intervention patients more frequently received assessment s of glycosolated hemoglobin ( 79 % versus 67 % ; P = .01 ) , LDL-C ( 69 % versus 55 % ; P = .009 ) , blood pressure ( 86 % versus 79 % ; P = .08 ) , microalbuminuria ( 40 % versus 30 % ; P = .05 ) , smoking status assessment ( 43 % versus 31 % ; P = .02 ) , and foot exams ( 38 % versus 20 % ; P = .0005 ) . Intervention patients had more planned general medicine visits ( 7.9 ± 6.2 versus 6.2 ± 5.7 ; P = .006 ) than did control patients . Interprofessional learners rated themselves significantly higher on measures of accomplishment , preparation , and success for chronic care than did the usual care learners . Conclusions Interprofessional team care by learners was effective in improving quality of care for adult patients with diabetes treated in general medicine clinics . The chronic illness framework result ed in more appropriate health care utilization Background Diabetes is a major challenge for the health care system and especially for the primary care provider . The Chronic Care Model represents an evidence -based framework for the care for chronically ill . An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters . However , most of these findings have been performed in setting s different from the Swiss health care system which is dominated by single h and ed practice s. Methods / Design CARAT is a cluster r and omized controlled trial with general practitioners as the unit of r and omization ( trial registration : IS RCT N05947538 ) . The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year ( primary outcome ) . Furthermore , we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure ( < 130/80 ) , HbA1c ( = < 6.5 % ) and low-density lipoprotein-cholesterol ( < 2.6 mmol/l ) , increases patients ' quality of life ( SF-36 ) and several evidence -based quality indicators for diabetes care . These improvements in care will be experienced by the patients ( PACIC-5A ) as well as by the practice team ( ACIC ) . According to the power calculation , 28 general practitioners will be r and omized either to the intervention group or to the control group . Each general practitioner will include 12 patients suffering from diabetes type II . In the intervention group the general practitioner as well as the practice nurse will be trained to perform care for diabetes patients according to the Chronic Care Model in teamwork . In the control group no intervention will be applied at all and patients will be treated as usual . Measurements ( pre- data - collection ) will take place in months II-IV , starting in February 2010 . Follow-up data will be collected after 1 year . Discussion This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach . If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to re design care in Switzerl and BACKGROUND A new diabetes shared care service was introduced in North Dublin . It was design ed as a r and omized controlled trial with a complex intervention comprising education of participating practitioners , the introduction of a community-based diabetes nurse specialist , local agreement on clinical protocol s and structured communication across the primary - secondary care interface . OBJECTIVES Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care . METHODS A Cluster r and omized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practice s in North Dublin . Biophysical outcomes ( HbA1c , blood pressure , body mass index ) , psychosocial measures ( smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores ) and process outcomes were collected . RESULTS There were significant improvements in diabetes care delivery and in psychosocial outcomes , but no significant improvements in biomedical outcomes . Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual review s and fewer patients defaulting from care . There were also significant improvements in information exchange between primary and secondary care . CONCLUSION Structured diabetes shared care , in a mixed health care system , can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients , with improved information exchange across the primary - secondary care interface Purpose : To study the effectiveness of multidisciplinary nurse practitioner coordinated team ( NPCT ) group visits  in medically underserved Appalachia on the health , knowledge , and self‐efficacy of patients with type 2 diabetes ( DM ) . The study also identified perceived barriers to participating in the diabetes programs . Data sources : A research er‐developed tool was used to assess demographic data , clinical data , and barriers to care . The participants completed the Diabetes Knowledge Tests and the Diabetes Empowerment Scales . Two groups were assessed . One group participated in the diabetes intervention , and the other received usual care . Both groups completed the instruments prior to the intervention and after the intervention was completed . Conclusions : The group that participated in the intervention had better clinical outcomes ( blood glucose and A1Cs ) , greater knowledge , and better self‐efficacy following the intervention than the usual care groups . This suggests that the intervention was important in improving outcomes of patients with type 2 DM .  Barriers to care included fuel , time , family , work , and transportation . Barriers need to be addressed in order to have more patients participate in such programs . Implication s for practice : NPCT group visits may represent an effective means of integrating diabetes self‐management education and medical management in a family practice clinic in medically underserved areas OBJECTIVE In a r and omized , multi-centre trial , the effect of an education programme ( MEDIAS 2 ICT ) involving intensive insulin treatment for people with type 2 diabetes was compared with an established education programme as an active comparator condition ( ACC ) . METHODS We investigated whether MEDIAS 2 ICT was non-inferior to ACC in overall glycaemic control . Secondary outcomes were the diabetes-related distress , diabetes knowledge , quality of life , self-care behavior , lipids , blood pressure and weight . RESULTS 186 subjects were r and omized . After a six month follow-up the mean HbA1c decrease was 0.37 % ( from 8.2±1.1 % to 7.8±1.5 % ) in the ACC and 0.63 % ( from 8.5±1.5 % to 7.9±1.2 % ) in MEDIAS 2 ICT . The mean difference between both groups was -0.26 % ( 95 % CI -0.63 to -0.14 ) in favor of MEDIAS 2 ICT . This result was within the predefined limit for non-inferiority . Diabetes-related distress was significantly more reduced in MEDIAS 2 ICT ( -3.4±7.1 ) than in ACC ( 0.4±9.0 ; p=0.31 ) . CONCLUSION MEDIAS 2 ICT is as effective in lowering HbA1c as previously established education programmes , but showed superiority in reducing diabetes-related distress . PRACTICAL IMPLICATION S MEDIAS 2 ICT provides an alternative for education of people with type 2 diabetes treated by multiple injection therapy BACKGROUND To study the effects of two different structured shared care interventions , tailored to local needs and re sources , in an unselected patient population with type 2 diabetes mellitus . METHODS A three-year prospect i ve observational study of two interventions and st and ard care . The interventions involved extensive ( A ) or limited ( B ) task delegation from general practitioners to hospital-liaised nurses specialised in diabetes and included a diabetes register , structured recall , facilitated generalist-specialist communication , audit and feedback , patient-specific reminders , and emphasised patient education . The target population consisted of 2660 patients with type 2 diabetes treated in the primary care setting . Patients who were terminally ill or who had been diagnosed with dementia were excluded from the study . RESULTS The participation rates were high ( 90 % ) for patients , and none of the 64 GPs discontinued their participation in the study . Longitudinal analyses showed significant improvements in quality indicators for both intervention groups ( process parameters and achieved target values on the individual patient level ) ; in st and ard care , performance remained stable or deteriorated . Both patients and caregivers appeared satisfied with the project . CONCLUSION This study shows that structured shared care with task delegation to nurses , targeted at a large unselected general practice population , is feasible and can positively affect the quality of care for patients with type 2 diabetes Abstract Objectives : To evaluate integrated care for diabetes in clinical , psychosocial , and economic terms . Design : Pragmatic r and omised trial . Setting : Hospital diabetic clinic and three general practice groups in Grampian . Patients : 274 adult diabetic patients attending a hospital clinic and registered with one of three general practice s. Intervention - R and om allocation to conventional hospital clinic care or integrated care . Integrated care patients seen in general practice every three or four months and in the hospital clinic annually . General practitioners were given written guidelines for integrated care . Main outcome measures : Metabolic control , psychosocial status , knowledge of diabetes , beliefs about control of diabetes , satisfaction with treatment , disruption of normal activities , numbers of consultations and admissions , frequency of metabolic monitoring , costs to patients and NHS . Results - A higher proportion of patients defaulted from conventional care ( 14 ( 10 % ) ) than from integrated care ( 4 ( 3 % ) , 95 % confidence interval of difference 2 % to 13 % ) . After two years no significant differences were found between the groups in metabolic control , psychosocial status , knowledge , beliefs about control , satisfaction with treatment , unscheduled admissions , or disruption of normal activities .  Integrated care was as effective for insulin dependent as non-insulin dependent patients . Patients in integrated care had more visits and higher frequencies of examination . Costs to patients were lower in integrated care ( mean pounds sterling 1.70 ) than in conventional care ( pounds sterling 8) . 88 % of patients who experienced integrated care wished to continue with it . Conclusions : This model of integrated care for diabetes was at least as effective as conventional hospital clinic care Purpose The purpose of this study was to examine whether integrating depression treatment into care for type 2 diabetes mellitus among older African Americans improved medication adherence , glycemic control , and depression outcomes . Methods Older African Americans prescribed pharmacotherapy for type 2 diabetes mellitus and depression from physicians at a large primary care practice in west Philadelphia were r and omly assigned to an integrated care intervention or usual care .  Adherence was assessed at baseline , 2 , 4 , and 6 weeks using the  Medication Event Monitoring System to assess adherence . Outcomes assessed at baseline and 12 weeks included st and ard laboratory tests to measure glycemic control and the Center for Epidemiologic Studies Depression Scale ( CES-D ) to assess depression . Results In all , 58 participants aged 50 to 80 years participated . The proportion of participants who had 80 % or greater adherence to an oral hypoglycemic ( intervention 62.1 % vs usual care 24.1 % ) and an antidepressant ( intervention 62.1 % vs usual care 10.3 % ) was greater in the intervention group in comparison with the usual care group at 6 weeks . Participants in the integrated care intervention had lower levels of glycosylated hemoglobin ( intervention 6.7 % vs usual care 7.9 % ) and fewer depressive symptoms ( CES-D mean scores : intervention 9.6 vs usual care 16.6 ) compared with participants in the usual care group at 12 weeks . Conclusion A pilot r and omized controlled trial integrating type 2 diabetes mellitus treatment and depression was successful in improving outcomes among older African Americans . Integrated interventions may be more feasible and effective in real-world practice s with competing dem and s for limited re sources OBJECTIVE The aim of this study was to examine patient-reported outcomes in a controlled trial of a multifaceted provider-level intervention to improve quality of care for rural patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a before/after intervention study with concurrent controls in two rural regions in Alberta , Canada . The intervention consisted of six monthly visits by a multidisciplinary health care team and was primarily directed at primary care providers .  Clinical and patient-reported outcomes were assessed after 6 months . Patient-reported outcomes included changes in health-related quality of life ( Health Utilities Index Mark 3 [ HUI3 ] ) , satisfaction with care , lifestyle ( Diabetes Lifestyle Form ) , and adherence to self-care activities . Analysis of covariance was used to assess differences over time between the control and intervention regions . RESULTS A total of 200 intervention and 172 control subjects were included in this analysis . After adjusting for important clinical and demographic differences , a statistically significant and clinical ly important improvement in the overall HUI3 score was seen at the 6-month follow-up in the intervention region ( 0.06 [ 95 % CI 0.02 - 0.10 ] ) compared with the control region ( 0.01 [ -0.04 to 0.04 ] ) ( P = 0.03 for the difference between groups ) . Satisfaction with general medical care ( P < 0.001 between groups ) and diabetes care ( P < 0.001 between groups ) increased among patients in the intervention region compared with the control region . Self-efficacy , attitudes , and beliefs about diabetes control all increased in the intervention region when compared with the control region , but adherence to self-care activities did not . CONCLUSIONS A provider-level intervention directed at improving quality of clinical care for patients with type 2 diabetes also had a favorable impact on overall health-related quality of life , satisfaction with care , and other humanistic outcomes Purpose The purpose of this study was to determine if improvements observed in clinical , behavioral , and psychosocial outcomes measured at 12 months following a multifaceted diabetes care intervention were sustained at 3-year follow-up . Methods This study was a multilevel , nonblinded , cluster design , r and omized controlled trial that took place in an under-served suburb of Pittsburgh , Pennsylvania , between 1999 and 2005 . Eleven primary care practice s , and their patients , were r and omly assigned to 3 groups :  chronic care model ( CCM ) intervention ( n = 30 ) , provider education only ( PROV ) ( n = 38 ) , and usual care ( UC ) ( n = 51 ) . Subjects were followed for 3 years . Results Improvements observed at 12-month follow-up in glycemic ( —0.5 % ) and blood pressure control ( —4.8 mm Hg ) , and the proportion of participants who self-monitor their blood glucose ( 86.7%-100 % ) , were sustained at 3-year follow-up in the CCM group . Additional improvements occurred in non-HDLc levels in all study groups and quality of well-being scores in the CCM intervention group . All associations remained after controlling for medication treatment intensification . Conclusions We have demonstrated that improvements in outcomes can be sustained over time following a multifaceted diabetes care intervention . Future research in this area is necessary to underst and if improvements in outcomes can be sustained following diabetes self-management education ( DSME ) and what type of patient fares the best from multifaceted diabetes care interventions OBJECTIVE Despite good evidence and clinical practice guidelines , studies document that treatment of type 2 diabetes is less than optimal . Lack of re sources or limited access may put patients in rural communities at particular risk for suboptimal care . RESEARCH DESIGN AND METHODS We conducted a prospect i ve , before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service ( intervention ) for improving the quality of care for rural patients with type 2 diabetes . Our intervention consisted of six monthly visits by a traveling team of specialist physicians , nurses , dieticians , and a pharmacist . The core of this service was specialist-to-rural primary care physician academic group detailing . Two comparable regions in Northern Alberta were r and omly allocated to control or intervention . Data were collected before and 6 months after intervention in a representative volunteer sample . The primary outcome was a 10 % improvement in any one of the following : blood pressure , total cholesterol , or HbA(1c ) . RESULTS Our analysis included 200 intervention and 179 control subjects ; 14 subjects were at all three primary outcome targets at baseline . The intervention was associated with a trend toward improvement in primary outcome at 6 months ( 44 % intervention vs. 37 % control ; odds ratio 1.32 , 95 % CI 0.87 - 1.99 ) . The intervention was associated with a significant improvement in blood pressure ( 42 % intervention vs. 25 % control , P = 0.004 ) ; however , there were only small , nonsignificant changes in cholesterol or HbA(1c ) . The intervention was associated with a significant increase in satisfaction with diabetes care . Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results . CONCLUSIONS A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients . Future studies need to involve longer timelines and larger sample sizes PURPOSE Depression commonly accompanies diabetes , result ing in reduced adherence to medications and increased risk for morbidity and mortality . The objective of this study was to examine whether a simple , brief integrated approach to depression and type 2 diabetes mellitus ( type 2 diabetes ) treatment improved adherence to oral hypoglycemic agents and antidepressant medications , glycemic control , and depression among primary care patients . METHODS We undertook a r and omized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care . Patients were r and omly assigned to an integrated care intervention or usual care . Integrated care managers collaborated with physicians to offer education and guideline -based treatment recommendations and to monitor adherence and clinical status . Adherence was assessed using the Medication Event Monitoring System ( MEMS ) . We used  glycated hemoglobin ( HbA1c ) assays  to measure glycemic control and the 9-item Patient Health Question naire ( PHQ-9 ) to assess depression . RESULTS Intervention and usual care groups did not differ statistically on baseline measures . Patients who received the intervention were more likely to achieve HbA1c levels of less than 7 % ( intervention 60.9 % vs usual care 35.7 % ; P < .001 ) and remission of depression ( PHQ-9 score of less than 5 : intervention 58.7 % vs usual care 30.7 % ; P < .001 ) in comparison with patients in the usual care group at 12 weeks . CONCLUSIONS A r and omized controlled trial of a simple , brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care . An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practice s with competing dem and s for limited re sources Background Physical activity ( PA ) and nutrition are the cornerstones of diabetes management . Several review s and meta-analyses report that PA independently produces clinical ly important improvements in glucose control in people with Type 2 diabetes . However , it remains unclear what the optimal strategies are to increase PA behaviour in people with Type 2 diabetes in routine primary care . Methods This study will determine whether an evidence -informed multifaceted behaviour change intervention ( Movement as Medicine for Type 2 Diabetes ) targeting both consultation behaviour of primary healthcare professionals and PA behaviour in adults with Type 2 diabetes is both acceptable and feasible in the primary care setting . An open pilot study conducted in two primary care practice s ( phase one ) will assess acceptability , feasibility and fidelity . Ongoing feedback from participating primary healthcare professionals and patients will provide opportunities for systematic adaptation and refinement of the intervention and study procedures . A two-arm parallel group clustered pilot r and omised controlled trial with patients from participating primary care practice s in North East Engl and will assess acceptability , feasibility , and fidelity of the intervention ( versus usual clinical care ) and trial processes over a 12-month period . Consultation behaviour involving fidelity of intervention delivery , diabetes and PA related knowledge , attitudes/beliefs , intentions and self-efficacy for delivering a behaviour change intervention targeting PA behaviour will be assessed in primary healthcare professionals . We will rehearse the collection of outcome data ( with the focus on data yield and quality ) for a future definitive trial , through outcome assessment at baseline , one , six and twelve months . An embedded qualitative process evaluation and treatment fidelity assessment will explore issues around intervention implementation and assess whether intervention components can be reliably and faithfully delivered in routine primary care . Discussion Movement as Medicine for Type 2 Diabetes will address an important gap in the evidence -base , that is , the need for interventions to increase free-living PA behaviour in adults with Type 2 diabetes . The multifaceted intervention incorporates an online accredited training programme for primary healthcare professionals and represents , to the best of our knowledge , the first of its kind in the United Kingdom . This study will establish whether the multifaceted behavioural intervention is acceptable and feasible in routine primary care . Trial registration Movement as Medicine for Type 2 Diabetes ( MaMT2D ) was registered with Current Controlled Trials on the 14th January 2012 : IS RCT N67997502 . The first primary care practice was r and omised on the 5th October 2012 Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier :
It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level , especially by increasing staff involvement and satisfaction .
Background Integrated care interventions for chronic conditions can lead to improved outcomes , but it is not clear when and why this is the case .
This study aims to answer the following two research questions : First , what are the context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?
Second , what are the relationships between context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?