| Redesigning Care Delivery in Rural Fee-for-Service Practices
Who is the intervention targeting?
African American patients with diabetes, their providers, and a rural primary health care system
What intervention is being evaluated?
Based on the Chronic Care Model, primary care practices will be redesigned to include the following components:
-
A circuit rider methodology in which a certified diabetes educator (CDE) nurse, dietitian and CDE qualified pharmacist rotate to clinics and partner with providers during patient visits as care managers
-
An electronic health record disease registry system with physician decision support
-
A four-part American Diabetes Association (ADA) patient curriculum
-
Self-management support interventions
-
Culturally relevant educational tools
-
Community-based follow-up and support services
Where is this intervention taking place?
This project will be undertaken by an experienced collaborative involving: small rural hospitals, rural community health center practices, a regional medical school, and a pharmacy school program at a historically black university in eastern North Carolina.
Partnering Organizations
Bertie Memorial Hospital/University Health Systems (Lead Organization)
East Carolina University
Elizabeth City State University
Eastern Carolina Association for Research and Education
Roanoke Chowan Hospital
Why might this approach work?
This intervention is directed a multiple components of the health care system including patients, providers, and the health care organizational structure. Multi-component interventions have been shown to improve chronic disease outcomes for minority patients.
How will this intervention be evaluated?
A prospective cohort study involving 360 African American adults is occurring at three primary care practices that have been participated in the system redesign. A similar group of 360 African American adults from three different primary care practices serve as the comparison group. All data will come from existing electronic records/diabetes registries in these practices or abstracted from traditional medial records. The study will specifically evaluate the effect of the redesigned model on glycemic control (HbA1c), blood pressure, and lipid levels from baseline to 6 and 12 months follow-up.
Principal Investigators:
Paul Bray, MA, LMFT
University Health Systems-Bertie Memorial Hospital
Doyle M. "Skip" Cummings, PharmD, FCP, FCCP
Brody School of Medicine, East Carolina University
For More Information
Please contact:
Paul Bray
pbray@pcmh.com | 
