Affiliated with East Carolina University, Brody School of Medicine, Department of Family Medicine
Publications from

     NCHP Research Cohort Project      Diabetes Disparities-RWJ Study      Hyperlink      Hyperlink      Hyperlink      Hyperlink     
Eastern Carolina Association for Research & Education

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


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: 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


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: 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)


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:

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


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:

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

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:

The following is a introduction to PCMH as published on the National Committee for Quality Assurance web site:

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: Why Improve Quality M3.mp4 model of QI and Primary Care.mp4 Intro to Quality Improvement for R1 revised.ppt ________________________________________
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