Sometimes it’s a knock on the door that can make all the difference. Bamberg diabetes transitional Care feasibility study – April, 2016 update Sometimes it’s a knock on the door that can make all the difference.

Study goals, groups and demographics Study Goal: Explore the impact and feasibility of different diabetes interventions for patients transitioning from hospital to home. The study compares three approaches to diabetes management: 1) community health worker (CHW) in-home intervention, 2) nurse care coordination via phone, or 3) standard physician instructions alone.  Participant Groups: Forty-eight participants completed the study CHW Group (n=24), Nurse Group (n=20), Usual Care Group (n=4) Demographics Average age of 59, 73% female, 90% African American, 42% married 81% have a high school education or less, 70% make less than $20,000 per year The overarching goal is to establish a cost-effective best practice diabetes management model to be disseminated to reduce unnecessary hospital readmissions and improve selfcare for members of this diverse high risk, underserved community. Marital Status: Married – 50% in CHW group, 30% RN group; Widowed – 16.7% CHW group, 25% RN group Education: ~ 80% in both groups had a high school education or less, but of those the RN group had a lower percentage who graduated high school (60% CHW, 25% RN) Income Level: A higher percentage in the RN group had less than $10k/year (24% CHW, 39% RN)

Study Outcomes A1C (CHW Group, n=20; RN, Group n=15) Blood Pressure Over half of both CHWs participants (65%) and RN participants (60%) improved their A1C over the course of the study. The average improvement in A1C in the CHW Group (A1C = 0.93) was higher than in the Nurse Group (A1C = 0.42). Blood Pressure A higher percentage of participants in the CHW group versus the Nurse Group had an improved systolic (48% vs. 20%) and diastolic (61% vs. 47%) blood pressure. Depression Over half of the CHW Group (58%) and Nurse Group (60%) reported fewer depressive symptoms at the end of the study compared to the beginning of the study. While at the beginning of the study 29.2% (6 CHW, 8 Nurse) reported no depressive symptoms, at the end of the study 58.3% (12 CHW, 16 Nurse) reported no depressive symptoms. The pre-study A1C for both groups was 9.63. The post-study A1C average was 8.7 for the CHW Group and 9.32 for the RN Group. monitoring and tracking A1c and blood pressure simple self-management coaching strategies accessing/enhancing resources supporting medication management, discharge plan adherence, problem solving, and improved diet and physical activity. addressing barriers and facilitators identified in Phase 1. Coaching Strategies Motivational interviewing, teach-back, collaborative goal-setting and review Health Behaviors Focus Healthy eating (31%), being active (23%), monitoring blood sugar (14%), taking medication (10%), other Reduced hospitalization and cost-effectiveness South Carolina Revenue and Fiscal Affairs Office will provide data 2 years prior and 1 year following study for participants and a comparison group

A successful partnership: participants and interventionists Jeannie Davis, 73 (pictured in slide), said she didn’t even know what her A1C level was before the study. She never had taken a class on how to manage it either. She joined the study when she had to go to the Regional Medical Center’s Bamberg Urgent Care. Being part of the study has encouraged her to take her medication and keep track of her blood pressure. She exercises more and eats better. “Knowing that Horace was coming, I had to always be ready and prepared,” she said of Horace Britton, her assigned community health worker. “I want to lose more weight and get and keep my A1C in check. I want to be off medication one day. I would participate again if I could.” Study Awareness and Dissemination: 2013 Institute of Medicine’s review of CTSA’s Report MUSC Press Release - August 2014 UNC Press Release - August 2014 MUSC Story in time for NCATS Visit – April 2016 Community Dissemination Plan Public forums, customized reports for practices, summary report for participants Manuscripts, publications, future grants Discussion Mary Brown, Nurse Interventionist Horace Britton, CHW and 2 Participants “Despite all of the things in my life despite that I have to take care of my children and my mother, and I have to work 12-hour shifts that change every day, I have the support of people who make me matter and care and teach me objective things.”

Acknowledgements Partners Study Staff Funders Dr. Leroy Davis – Voorhees College Brenda Williams – The Regional Medical Center (tRMC) Mayor Blain Crosby of Bamberg Mayor Gerald Wright of Denmark Diabetes Initiative of South Carolina Funders SCTR, MUSC NC TraCS, UNC-Chapel Hill South Carolina Department of Health and Human Services