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Many primary care patients, especially in inner-city settings, do not achieve targets for blood pressure and glycemic control. There is an urgent need to enhance treatment for those who do not reach goals within the usual clinical care system. We propose to develop a multi-component intervention grounded in the Chronic Care Model, and sustainable in resource-challenged settings. Through collaboration with home health nursing and with the use of home telemetry for feedback and intensification of therapy, we will augment usual clinical services to improve health outcomes for diabetes patients who have not been able to reach therapeutic goals. There are three specific aims. First, we will establish a feasible, practical and sustainable collaborative model between the primary care sites of our practice-based research network (NYC RING), clinical researchers at the Diabetes Research and Training Center, and The Montefiore Home Health Organization, integrating the unique expertise of each of the partners and defining the roles and responsibilities of each. Second, we will develop and refine the components of the intervention, to include training primary care providers and home health nurses to integrate the technical, psychosocial and communication processes for implementation of the intervention. Third, we will assess the feasibility of the collaborative intervention by implementing the intervention for 25 primary care patients and obtain preliminary estimates of effectiveness by comparing outcomes to 25 patients receiving usual care. Our proposal includes plans to develop feasible procedures for data collection, with qualitative and quantitative methods of assessing process and outcome measures. We will use these preliminary data to revise the intervention and prepare an R18 application to further develop and test the intervention in multiple inner-city primary care sites serving low-income diabetes patients. This proposal is for secondary prevention of diabetes complications, targeting a population known for health disparities and a high burden from this chronic disease.
Allocation: Randomized, Intervention Model: Single Group Assignment, Primary Purpose: Health Services Research
Type 2 Diabetes
home health/primary care collaboration
Albert Einstein College of Medicine
Albert Einstein College of Medicine of Yeshiva University
Published on BioPortfolio: 2014-08-27T03:12:50-0400
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Nursing care given to an individual in the home. The care may be provided by a family member or a friend. Home nursing as care by a non-professional is differentiated from HOME CARE SERVICES provided by professionals: visiting nurse, home health agencies, hospital, or other organized community group.
Those unable to leave home without exceptional effort and support; patients (in this condition) who are provided with or are eligible for home health services, including medical treatment and personal care. Persons are considered homebound even if they may be infrequently and briefly absent from home if these absences do not indicate an ability to receive health care in a professional's office or health care facility. (From Facts on File Dictionary of Health Care Management, 1988, p309)
Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals.
A nursing specialty in which skilled nursing care is provided to patients in their homes by registered or licensed practical NURSES. Home health nursing differs from HOME NURSING in that home health nurses are licensed professionals, while home nursing involves non-professional caregivers.
Persons who assist ill, elderly, or disabled persons in the home, carrying out personal care and housekeeping tasks. (From Slee & Slee, Health Care Terms. 2d ed, p202)
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