Electronic Frailty Index (eFI)Cacious-Diabetes Care

This study is a pragmatic pilot study assessing the feasibility and acceptability, and preliminary impact of a pharmacist-led care pathway to align patient care with guidelines for type 2 diabetes mellitus (T2DM) management in frail older adults, leveraging existing resources and pathways of care led by Clinical Prescribing Pharmacists. Eligible participants will be identified from the Electronic Health Record (EHR). Research staff will then approach the primary care physicians for identified patients to confirm that patients are appropriate for the intervention, as determined by the primary care physician (PCP). Patients will then be contacted both by letter and phone call, and invited to participate in the pharmacist-led pathway. Telephonic informed consent will be obtained. Outcomes for all participants will be accessed passively via the EHR. The study team hypothesizes that patients who go through the pharmacist-led primary care intervention will be more likely to have guideline-concordant medical therapy as compared with an EHR-based control group. Also, the study team believes that the intervention will reach at least 50% of those referred by their physicians to participate, the median number of outpatient visits will be three or less, and that the intervention will require a total of <3 hours for pharmacists and patients across the 3-month intervention period. In addition, the study team expects patients, physicians, and pharmacists will report the intervention is feasible, acceptable, appropriate, and high-value. Lastly, the study team believes that the intervention group will have a lower mortality than the comparison group.

Inclusion criteria

• Attributed to a Atrium Health Wake Forest Baptist-affiliated Accountable Care Organization
• At least 2 consecutive International Classification of Diseases 10th Revision (ICD-10) codes for type two diabetes mellitus in the prior 2 years
• Has a calculable Electronic Frailty Index (eFI) score >0.21
• A glycosylated hemoglobin (HbA1c) value <7.5% in the prior 2 years
• Currently taking a sulfonylurea or insulin for Type 2 Diabetes Mellitus (T2DM)

Exclusion criteria

• Moderate to severe hearing loss (due to phone interventions)
• Diagnosed Alzheimer's disease or related dementia (unable to participate)
• Non-English speaking (not all pharmacists speak a second language; subtleties may not be conveyed effectively)
• No phone number available for patient (follow up contacts will be by telehealth or phone