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Health Services Research & Development

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HSR&D In Progress

December 2020

In This Issue: Enhancing Primary Care for Veterans with Chronic Illness
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Engaging Veterans and Family Supporters in PACT to Improve Diabetes Management

Feature Article

Takeaway: This study will establish a new approach for involving patients' supporters in VA care, in ways that could avert devastating consequences of uncontrolled diabetes. Similar methods could be used by VA and others to better support Veterans' family caregivers, and to improve health management for Veterans with other high-risk conditions.

VA’s PACT (Patient-Aligned Care Team) initiative seeks to provide patients with comprehensive, team-based support for following diabetes care regimens. PACT's success hinges on its ability to effectively engage patients in care. One relatively untapped resource for supporting this engagement is patients' family and friends. However, 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 – family members or friends who might be able to help Veterans better control blood pressure, hyperglycemia, or hyperlipidemia associated with diabetes.

This ongoing randomized controlled trial (June 2015 – September 2021) is evaluating an intervention, titled Caring Others Increasing EngageMent in PACT (or CO-IMPACT), which builds on medical record-integrated patient activation tools in the PACT toolkit and is designed to be implementable within existing PACT nurse encounters. Study investigators recruited VA patients with diabetes receiving PACT primary care who: 1) are at high risk for diabetes complications due to hyperglycemia or high blood pressure, and 2) have a health supporter involved in their care. Two hundred and thirty nine adults with diabetes and at high risk for diabetes complications due to poor glycemic control or high blood pressure were randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months.

Primary outcomes for this study include a validated measure of 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 among supporters include supporter activation, use of effective support techniques, distress about patient's diabetes care, and caregiver burden. Investigators also are measuring the quality of patient-supporter and patient-provider relationships, patient safety (e.g. hypoglycemia), utilization, potential moderators of intervention effect such as patient health literacy level, and facilitators and barriers to wider intervention implementation.


The CO-IMPACT study was very successful at recruiting and engaging Veteran and caregiver dyads: 239 Veteran + caregiver dyads were enrolled at two VA primary care sites. The study showed high engagement, with 75% of biweekly virtual contacts completed by participants over a one-year period, and high retention, with 95% of originally enrolled patients completing 12-month survey and laboratory assessments.

Thus far, results show that 94% of Veterans and 83% of caregivers reported the program helped Veterans improve their diabetes management. Further, Veterans reporting that they were satisfied with VA support for involving their caregiver in their healthcare rose from 53% to 84% in the intervention group. Veterans with high diabetes distress report more supporter help with medically focused self-management (i.e., taking medications, coordinating medical care) but not with diet and exercise.

Anticipated Impact

CO-IMPACT will provide VA healthcare teams with evidence-based tools and techniques to engage patients' available family or friends in supporting patient self-management, even if they live remotely, which is an advantage during the pandemic. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities.

Principal Investigator: Ann-Marie Rosland, MD, MS, is an investigator with HSR&D’s Center for Health Equity Research & Promotion (CHERP) and also is part of the VA Pittsburgh Healthcare System.


Lee A, Heisler M, Trivedi R, et al.. Diabetes distress among dyads of patients and their health supports: Links with functional support, metabolic outcomes, and cardiac risk. Annals of Behavioral Medicine. October 12, 2020. Epub ahead of print.

Rosland AM, 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 24, 2018;19(1):394.

View study abstract

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