Table 3.
Characteristics of practice sites, model adopted, and estimated reach among patients with type 2 diabetes mellitus (T2DM) with suboptimal glycemic control seen during implementation period
| Total client base | Uninsured (%) | Medicaid (%) | African-American (%) | Hispanic (%) | <100 % FPL | NCQA designation | Mean baseline ACIC scores | Model adopted | Patients targeted | Communication with primary care providers about patient goals and follow-up | Reacha (%) | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Site A | 13,035 | 35 | 31 | 27 | 13 | 52 | PCMH | SMS = 6.6b
Overall = 6.7 |
Clinic nurse | All patients | Notes in electronic health record | 239/839 (29) |
| Site B | 13,238 | 48 | 28 | 14 | 25 | 75 | PCMH | SMS = 6.2 Overall = 6.0 |
Nurse care manager | High-risk patients | Daily huddles | 153/1089 (14) |
| Site C | 15,150 | 36 | 28 | 8 | 39 | 25 | PCMH | SMS = 6.6 Overall = 7.5 |
Health educator case manager | High-risk patients; clinical judgment | As needed | 129/1381 (9) |
| Site D | 24,717 | 39 | 37 | 24 | 13 | 36 | None | SMS = 5.5 Overall = 5.0 |
N/A | N/A | N/A | N/A |
FPL federal poverty level, NCQA National Committee for Quality Assurance, ACIC Assessment of Chronic Illness Care, PCMH Patient-Centered Medical Home, N/A not applicable
aNumber of patients who received the intervention/number of patients seen in the site during the implementation period with suboptimal glycemic control (A1C ≥ 7.5 %)
bSelf-Management Support subscale score