Equitably Assessing the Impact of a Coordinated, Multidisciplinary Diabetes Care Model using Implementation Science and Participatory Approaches ​

Research Model

The program targets low-income, Medicaid-eligible individuals with prediabetes, diabetes, and other endocrine disorders and provide care through a coordinated, multidisciplinary team that includes Clinical team (clinical care, education and support), Pharmacy team (medication decisions, adherence), Social Workers, CHWs, Navigators (address social and emotional needs), and Data Analytics team (risk stratification and patient technology).

Evaluation Approach

The Implementation Science Framework will guide the Community Based participatory Research methods, and community health workers will conduct patient interviews to understand healthcare utilization, adherence, satisfaction, and health outcomes.

Contribution to HSTRC’s Research Agenda 

• Add to the evidence base on successful health system models aimed to address chronic disease burden in Medicaid-eligible populations in innovative and coordinated ways
• Explore the extent to which the Center integrates the RWJF-HSTRC Research Agenda’s seven priority components, and determine how this approach leads to increase healthcare effectiveness and improvement in patient outcomes
• Explore how equitable participatory methods in evaluation can improve and/or sustain patient satisfaction, patient engagement and sustainability of a healthcare model