Changing the Healthcare Delivery Model

This is a randomized controlled trial comparing 3 strategies to improve wellness behaviors and clinical goals for DM2 Medicaid patients with uncontrolled DM.

• Group 1 will be assisted by the Voxiva Care4Life mobile health disease management program (C4L) provided on the patient's cell phone.
• Group 2 will be assisted by CHWs who are members of the outpatient medical home health team.
• Group 3 will be assisted by both the Voxiva Care4Life mHealth disease management system (C4L) and a CHW.

Hypotheses:

• A patient interactive cell phone disease management system plus a community health worker (CHW) is superior to either a cell phone system or a CHW alone to activate DM2 Medicaid patients to improve a composite of 7 Wellness Behaviors and 6 Clinical Goals.
• A patient interactive cell phone disease management system will activate Medicaid patients with type 2 diabetes (DM2) to improve the composite of 7 wellness behaviors and 6 clinical outcomes by 25% or greater compared to baseline

Expected Outcomes:

Primary outcomes:

• Superior improvement over baseline of the composite of Wellness Behaviors and Clinical Outcomes in the CHW plus C4L group compared to the CHW alone and cell phone alone groups.
• Improvement by 25% or greater over baseline of the composite of Wellness Behaviors and Clinical Outcomes for patients using C4L alone.

Secondary outcomes:

Improvement in both clinical and behavior endpoints. Endpoints to be compared across the three treatment arms include:

• mean HbA1c,
• mean LDLc Cholesterol
• average BP if hypertensive
• Patient distress measured with Fisher Brief Diabetes Distress Screening Instrument

• Medication adherence measured with Morisky Medication Adherence Survey 5) Healthcare utilization: ER, acute clinic visits, hospitalizations

Anticipated results and impact on healthcare:

Mobile health has great potential to enhance DM2 patient health behaviors and clinical outcomes both alone and, even better, with assistance of a CHW. mHealth systems can be provided to a wide range of urban and rural DM2 patients resulting in an affordable, a more efficient patient-driven/centered health delivery system.

Inclusion criteria

• Age 21 to 75 years old
• Medicaid insurance coverage, Medicare insurance coverage or Affordable Health Care Act insurance coverage
• Fluent in English or Spanish and able to read a text message
• Diagnosed with diabetes mellitus type 2 and A1C is > 8%

Acceptable values will be either :

• A1c obtained within one month prior to baseline (as long as there were no diabetes changes made during that month) or
• A new A1c measured at the baseline screening visit.
• Meets < 10 of the wellness behaviors and clinical goals if diagnosed with hypertension Meets < 9 of the wellness behaviors and clinical goals if not diagnosed with hypertension

Exclusion criteria

• Stage 5 chronic kidney disease or end stage renal disease on dialysis
• Terminal illness (expected survival of less than one year)
• Severe dementia or uncontrolled mental illness
• Gestational diabetes mellitus
• Use of an insulin pump
• Inability to use a cellular phone
• Unable to use software application on cellular phone
• Pregnant or planning to get pregnant