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Eastern Carolina Association for Research & Education
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E-CARE is affiliated with the research programs of Department of Family
Medicine, East Carolina University, Brody School of Medicine. The
network is managed by a coordinator and directed by advisory staff
including clinicians from primary care departments at East Carolina University.
Improved Outcomes in Diabetes Care
for Rural African Americans
Paul Bray, MA LMFT; Debra Thompson, MSN, APRN, BC; Don Holbert, PhD;
Doyle M. Cummings, PharmD; Kyle Wilson, BS; Eric Lukosius, BS;
Robert Tanenberg, MD; and Susan Morrissey, MA;
Annals of Family Medicine, March 2013;11:145-150
ABSTRACT:
PURPOSE Rural low-income African American patients with diabetes have traditionally
poorer clinical outcomes and limited access to state-of-the-art diabetes
care. We determined the effectiveness of a redesigned primary care model on
patients’ glycemic, blood pressure, and lipid level control.
METHODS In 3 purposively selected, rural, fee-for-service, primary care practices,
African American patients with type 2 diabetes received point-of-care education,
coaching, and medication intensification from a diabetes care management team
made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control
practices matched for practice and patient characteristics, African American
patients received usual care. Using univariate and multivariate adjusted models,
we evaluated the effects of the intervention on intermediate (median 18 months)
and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin
A1c) levels, blood pressure, and lipid levels, as well as the proportion of
patients meeting target values.
RESULTS Among 727 randomly selected rural African American diabetic patients
(368 intervention, 359 control), intervention patients had a significantly greater
reduction in mean hemoglobin A1c levels at intermediate (–0.5 % vs –0.2%; P
<.05) and long-term (–0.5% vs –0.10%; P <.005) follow-up in univariate and
multivariate models. The proportion of patients achieving a hemoglobin A1c level
of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less
than 140 mm Hg (69% vs 57%, P <.01) was also signifi cantly greater in intervention
practices in multivariate models.
CONCLUSION Redesigning care strategies in rural fee-for-service primary care
practices for African American patients with established diabetes results in signifi -
cantly improved glycemic control relative to usual care.
Full Text in pdf format:
http://nc-e-care.com/Improved_
Outcomes_in_Diabetes_Care_for_Rural_African_Americans;_Paul_Bray_,MA,_LMFT.pdf
Confronting Disparities in Diabetes Care: The
Clinical Effectiveness of Redesigning Care
Management for Minority Patients in Rural
Primary Care Practices
Paul Bray, MA; Debra Thompson, MSN, APRN, BC; Joan D. Wynn, MSN RN;
Doyle M. Cummings, PharmD; and Lauren Whetstone, PhD;
Journal of Rural Health, v21 n4 p317-321 Oct 2005
ABSTRACT:
Diabetes mellitus and its
complications disproportionately affect minority citizens in
rural communities, many of whom have limited access to
comprehensive diabetes management services. Purpose: To
explore the efficacy of combining care management and
interdisciplinary group visits for rural African American
patients with diabetes mellitus. Methods: In the
intervention practice, an advanced practice nurse visited
the practice weekly for 12 months and facilitated diabetes
education, patient flow, and management. Patients
participated in a 4-session group visit education/support
program led by a nurse, a physician, a pharmacist, and
a nutritionist. The control patients in a separate practice
received usual care. Findings: Median hemoglobin A1c
(HbA1c) was not significantly different at baseline in the
intervention and control groups but was significantly
different at the end of the 12-month follow-up period
(P,.05). In the intervention group, median HbA1c at
baseline was 8.2 6 2.6%, and median HbA1c at an average
follow-up of 11.3 months was 7.16 2.3%, (P,.0001). In the
control group, median HbA1c increased from 8.3 6 2.0%
to 8.6 6 2.4% (P,.05) over the same time period. In the
intervention group, 61% of patients had a reduction in
HbA1c, and the percentage of patients with a HbA1c of
less than 7% improved from 32% to 45% (P,.05).
Conclusions: These findings suggest that a redesigned care
management model that combines nurse-led case
management with structured group education visits can be
successfully incorporated into rural primary care practices
and can significantly improve glycemic control.
Full Text in pdf format:
http://nc-e-care.com/confronting_disparities_in_
diabetes_care.pdf
Feasibility and Effectiveness of
System Redesign for
Diabetes Care Management
in Rural Areas
The Eastern North Carolina Experience
Paul Bray, MA, Melissa Roupe, MSN, RN, Sandra Young, MSN, RN,
Jolynn Harrell, BSN, Doyle M. Cummings, PharmD, FCP, FCCP
and Lauren M. Whetstone, PhD
The Diabetes Educator, Vol. 31, No. 5, 712-718 (2005)
ABSTRACT:
Redesigning the system of care for the management of
patients with type 2 diabetes mellitus has not been well
studied in rural communities with a significant minority
population and limited health care resources. This study
assesses the feasibility and potential for cost-effectiveness
of restructuring care in rural fee-for-service practices
for predominantly minority patients with diabetes
mellitus.
Full Text in pdf format:
http://nc-e-care.com/feasibility_and_effectiveness.pdf
Practice Characteristics Associated with Sustaining Quality
Improvement Initiatives
Paul Bray, MA, LMFT; Doyle M. Cummings, PharmD; Marti Wolf, RN, MPH;
Mark W. Massing, MD, PhD, MPH; and Janet Reaves, RN, MPH
Journal on Quality and Safety, Vol. 35, No. 10, 502-508,
Oct 2009
ABSTRACT:
While much has been written about the initial processes and outcomes associated
with quality improvement (QI) collaboratives, very little is known about the
processes required to sustain these quality improvement initiatives after
the initial funding and/or support declines. We sought, in the present study,
to better understand and describe the characteristics and/or activities
of group practices that are associated with sustaining quality improvement
initiatives five or more months after cessation of formal collaborative support.
The present study involved 25 inperson structured interviews in 13 purposefully
selected group practices in North Carolina that had actively participated in
a larger statewide collaborative quality improvement initiative to improve
chronic disease care involving a total of 33 practices. Themes were identified
by two separate investigators by analysis of total transcripts as well as by
content analysis for each question and grouping of common themes. The following
activities enhanced the likelihood of sustaining quality improvements in
collaboratives: 1) institutionalized meetings of QI teams in the presence of
current patient outcomes data, 2) leadership support through tangible actions
such as funding data entry personnel, 3) maximized billing and grants using QI
data, 4) publicity of QI achievements and 5) forming strategic partnerships
around QI data. In conclusion, our findings suggest the association of specific
practice characteristics and activities such as regular data reports,
leadership, and committed infrastructure and the sustaining of quality
improvement work. The sustainability model illustrates the relative importance
and hierarchical relationships among these practice characteristics and
activities required to sustain quality improvement work.
Full Text in pdf format:
http://nc-e-care.com/sustaining_qi_in_pracrices.pdf
Leadership in Interprofessional Health Education and Practice
- 2009 Jones and Bartlett Publishers
ISBN-13: 9780763749835
ISBN-10: 0763749834
$69.95 (Sugg. US List)
Main Authors
Charlotte Brasic Royeen, PhD, OTR/L, FAOTA, Dean, Edward and Margaret
Doisy College of Health Sciences, Professor, Department of Occupational
Science and Occupational Therapy, Saint Louis University
Gail M. Jenson, PhD, PT, FAPTA, Dean, Graduate School and Associate
Vice President in Academic Affairs, Professor, Department of Physical Therapy,
Faculty Associate, Center for Health Policy and Ethics, Creighton University
Robin Ann Harvan, EdD, Special Projects Associate, Offices of
the Vice Chancellor for Health Affairs and Dean of the School of Medicine,
Associate Professor, Department of Family Medicine,
University of Colorado-Denver
Chapter 17
Improving Diabetes Outcomes in Rural Practices: Power of Collaborative Care
Doyle M. Cummings, PharmD, BCPS, FCP, FCCP
Paul Bray, MA, LMFT
Maria C. Clay, PhD
Summary
Interprofessional patterns of care delivery are effective and are increasingly
becoming the norm for management of patients with diabetes mellitus and other
chronic conditions. Their inclusion in redesigned systems of care represents
an innovative model that requires a sharing of power, new structures or practice
patterns, and a culture shift away from traditional hierarchical models of care delivery.
The authors demonstrated that redesigned systems of care for diabetes mellitus can
be successfully established even in underserved rural communities and have
great potential to improve outcomes and diminish health disparities.
Training Family Practice Residents and Medical Students in "Patient
Centered Medical Home" (PCMH)concepts:
Summary
The following is a introduction to PCMH as published on the National
Committee for Quality Assurance web site:
http://www.ncqa.org/tabid/631/Default.aspx
The PPC®-PCMHTM program reflects the input of the American College of Physicians
(ACP), American Academy of Family Physicians (AAFP), American Academy of
Pediatrics (AAP) and American Osteopathic Association (AOA) and others in a
revision of Physician Practice Connections® to assess whether physician practices
are functioning as medical homes. Building on the joint principles developed
by the primary care specialty societies, the PPC®-PCMHTM standards emphasize
the use of systematic, patient-centered, coordinated care management processes.
The Patient Centered Medical Home is a health care setting that facilitates
partnerships between individual patients, and their personal physicians, and
when appropriate, the patient’s family. Care is facilitated by registries,
information technology, health information exchange and other means to assure
that patients get the indicated care when and where they need and want it in a
culturally and linguistically appropriate manner.
At East Carolina University, Paul Bray has produced the following two introductory
video's to PCMH concepts:
http://nc-e-care.com/ECU Why Improve Quality M3.mp4
http://nc-e-care.com/a model of QI and Primary Care.mp4
http://nc-e-care.com/ECU Intro to Quality Improvement for R1 revised.ppt
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