April 2019

In This Issue: Improving Care for Veterans with Diabetes
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Engaging Veterans and Family Supporters in PACT to Improve Diabetes Care

Feature Article

Veterans with diabetes must control cardiovascular risk factors to help prevent disabling and life-threatening complications. However, despite system-wide advances in diabetes quality of care, more than 30% of VA patients with diabetes continue to have uncontrolled blood pressure, hyperglycemia, or hyperlipidemia. The nationwide VA PACT (Patient-Aligned Care Teams) initiative seeks to provide patients with comprehensive, team-based support in following diabetes care regimens. PACT's success, however, hinges on its ability to effectively engage patients in care. One relatively untapped resource for supporting engagement in PACT is a patient’s family and friends. Three out of four adults with diabetes reach out to an unpaid family member or friend ('Care Partner') for ongoing help with diabetes management. These supporters help patients with medication adherence, tracking home glucose measurements, maintaining a healthy eating plan, and often accompany patients to their medical visits. While PACT emphasizes the importance of family members as part of the care team, PACT does not have formal mechanisms to involve health supporters in care. Moreover, health supporters report that in order to be more effective they need more information on patients’ medical care plans, clear channels for communicating with PACT team members, and information on navigating PACT resources.

The main objective of this ongoing (2015–2020) HSR&D randomized controlled trial is to test a strategy to strengthen the capacity of supporters to help patients with high-risk diabetes engage in PACT care and successfully enact care plans.  The intervention – Caring Others Increasing EngageMent in PACT (CO-IMPACT) – is designed to structure and facilitate health supporter involvement in PACT so that patients can become more actively engaged in PACT care. This trial includes 240 Veterans with diabetes receiving VA PACT primary care who are at high risk for diabetes complications due to hyperglycemia OR high blood pressure, and who have a health supporter involved in their care. Patient-supporter dyads were randomized to the CO-IMPACT intervention or usual PACT care for high-risk diabetes for 12 months. The CO-IMPACT intervention provides patient-supporter dyads with:

• One coaching session on action planning, communicating with providers, navigation skills, and support skills;
• Preparation by phone before patients' primary care visits;
• After-visit summaries by mail; and
• Biweekly automated phone calls to prompt action on new patient health concerns.

CO-IMPACT builds on medical record-integrated patient activation tools in the PACT toolkit and is designed to be implementable within existing PACT nursing encounters. Primary outcomes for this study include patient activation and a cardiac event 5-year risk score designed for patients with diabetes. Secondary outcomes include patients' self-efficacy for diabetes self-care; diabetes self-management behaviors, including medication adherence; diabetes distress; and glycemic and blood pressure control. Measures for supporters include supporter activation, use of effective support techniques, distress about patient's diabetes care, and caregiver burden. Investigators also are examining the quality of the patient-supporter and patient-provider relationship, patient safety (e.g. hypoglycemia), and facilitators and barriers to wider intervention implementation.

Findings: The target number of Veteran-Care Partner dyads was successfully recruited to the study over an 18-month period. By early summer 2019, 12-month outcomes data collection will be complete.

At baseline, CO-IMPACT has been able to examine how supporters were already helping patients before starting the study:

Veterans’ health supporters

Among enrolled supporters of Veterans with diabetes, 64% were spouse/partners, 21% other family, and 12% friends. Supporter roles in patient healthcare at baseline included attending at least some patient medical appointments (37%) and helping patients prepare for medical appointments (64%). Veterans’ health supporters were frequently involved in health decisions, such as when patients should call their doctor about symptoms (58% sometimes or more) and what to do when self-testing results changed (53%).Supporters often reminded patients to go to medical appointments (59%), take medications (54%), and do home testing (42%), but rarely directly gave insulin shots (11%) or did patients’ self-testing (7%). While playing these key roles, supporters faced their own challenges: more than half of supporters (57%) had low self-rated health status (good/fair/poor vs. excellent/very good), and 33% reported functional limitations due to physical health problems. Supporters also cared for minor children full time (27%) or part of the time (30%). 

Patient and supporter diabetes distress

At baseline, both patient distress about diabetes and supporter distress about the patient’s diabetes were each independently correlated with a half-point increase in patient’s HbA1c. Patients with high diabetes distress were approximately twice as likely to report that supporters helped them remember to do specific self-care activities, but they were not more likely to report encouragement for healthy lifestyle behaviors. Yet, supporters with high distress about patients’ diabetes were not more likely to engage in specific support roles, suggesting that supporters may respond to patients’ diabetes distress, but not their own.

Patient and supporter health literacy

Nearly one-third of enrolled Veterans had low health literacy (n=69, 30%), and these Veterans were more likely to also have a low health literacy supporter (32% of supporters of patients with low HL vs 18% of supporters of patients with high HL). Low patient health literacy was significantly associated with higher odds of supporters helping with: deciding when to call doctor, remembering medical appointments, navigating the health system, and attending medical appointments with patient. Patient health literacy was not associated with whether supporters helped with filling and taking medications or managing diet and exercise.

Impact: This study is expected to establish a new approach for involving patients' supporters in VA care, in ways that could avert disabling consequences of uncontrolled diabetes. Similar approaches also could be used by VA to better support Veterans' family caregivers for Veterans with other high-risk conditions.

Principal Investigator: Ann-Marie Rosland, MD, MS, is a former HSR&D Career Development Awardee, and is currently part of HSR&D’s Center for Health Equity Research & Promotion (CHERP), Pittsburgh, PA.  The study is being conducted at the VA Ann Arbor Healthcare System in collaboration with investigators at HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI.

Publications:

Rosland A, Piette J, Trivedi R, et al. Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial. Trials. July 2018;19(1):394.

View project abstract.