Diabetes, Hypertension, Congestive Heart Failure
Conditions
Keywords
care management, chronic disease, outpatient
Brief summary
Trained lay persons (care guides) working with chronic disease patients and their providers can help outpatients with diabetes, hypertension, and congestive heart failure achieve standard clinical care goals
Detailed description
In a randomized parallel group multi-site trial looking at achievement of standard recommended treatment goals at baseline and one year later by 2135 patients with diabetes, hypertension, and congestive heart failure, we tested the hypothesis that adding a lay person with brief training to usual care would improve clinical outcomes. These care guides were culturally matched to patients served, similar to community health workers, but were located in 6 diverse primary care health clinics where they could meet patients face-to-face. They were asked to assist communication in both directions between providers and patients, taking advantage of their status as non-authority figures. They were given two weeks' training about these diseases and behavior change theory. This intervention was designed to be low cost, easy to implement, and to integrate into rather than change clinic work flow.
Interventions
Patients receive education about care goals, and in-person and telephone counseling of unspecified frequency over one year to achieve goals
patients receive education about care goals
Sponsors
Study design
Eligibility
Inclusion criteria
* ages 18-79 * diagnoses of diabetes, hypertension, and/or congestive heart failure
Exclusion criteria
* pregnant * unable to understand randomization process
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| change in number of care goals met | one year | Predetermined care goals as recommended by national authorities such as American Diabetes Association, American Heart Association, JNC-7. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Kinds of patients who benefit from working with a care guide | one year | demographic, clinical, and attitudinal characteristics of patients who benefit |
Countries
United States