Post-Discharge Support for Type 2 Diabetes

(MEDBRIDGE Trial)

Not yet recruiting at 1 trial location
Age: 18+
Sex: Any
Trial Phase: Academic
Sponsor: University of Alabama at Birmingham
No Placebo GroupAll trial participants will receive the active study treatment (no placebo)

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to determine if a special support program can help people with type 2 diabetes manage their medications after hospital discharge. For three months, a nurse and a community health worker will assist patients by answering medication questions and coordinating care with their doctor. The program, called the MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention, seeks to assess its effectiveness in managing diabetes and reducing emergency visits. Individuals with type 2 diabetes who have recently been discharged from specific hospitals and are considered high-risk may be suitable candidates. As an unphased trial, this study provides a unique opportunity for patients to contribute to innovative care solutions and potentially improve their own health management.

What prior data suggests that this support program is safe for patients with type 2 diabetes?

Research has shown that nurse-led programs can safely and effectively manage diabetes. One study found that involving nurses and community health workers (CHWs) improved blood sugar control in patients, suggesting that the MEDBRIDGE-Guided support, which uses nurses and CHWs, is likely to be well-received.

Another study found that CHW programs improved diabetes management without causing serious side effects, indicating that the support planned in this trial is likely safe for participants. Additionally, Medication Therapy Management (MTM), a similar support service, has proven safe for people with diabetes.

Overall, these findings suggest that the support in this trial should be safe for participants. However, discussing any concerns with the trial doctors before joining is important.12345

Why are researchers excited about this trial?

Researchers are excited about the MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention because it offers a personalized approach to managing type 2 diabetes after hospital discharge. Unlike standard care, which often relies on routine follow-ups and medication adjustments, this treatment involves a team of nurse case managers and community health workers who provide targeted support based on individual risk assessments. This collaborative strategy aims to address specific patient needs and potentially improve outcomes by offering tailored interventions during a critical recovery period. By focusing on personalized care and community-based support, this approach could redefine post-discharge management for high-risk diabetes patients.

What evidence suggests that the MEDBRIDGE-Guided NCM/CHW Support is effective for managing type 2 diabetes post-discharge?

Research has shown that nurse case managers (NCMs) and community health workers (CHWs) can help people with type 2 diabetes improve their health. Studies have found that these support programs lead to fewer hospital visits and better blood sugar control. For example, patients who regularly met with NCMs and CHWs experienced 31% fewer hospital visits. Another study demonstrated that programs involving CHWs improved both health outcomes, such as blood sugar levels, and lifestyle changes. In this trial, participants will receive the MEDBRIDGE-guided NCM/CHW support intervention, which could help manage diabetes more effectively after leaving the hospital.34567

Who Is on the Research Team?

SL

Seung-Yup Lee, PhD

Principal Investigator

University of Alabama at Birmingham

Are You a Good Fit for This Trial?

This trial is for adults with type 2 diabetes who are leaving the hospital and may have trouble managing their medications. It focuses on those at higher risk of problems after discharge, especially in areas with limited healthcare access.

Inclusion Criteria

Discharged from UAB Hospital or its emergency departments
Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic
Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge
See 2 more

Exclusion Criteria

Currently enrolled in another post-discharge intervention study
Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care
I am younger than 18 years old.
See 2 more

Timeline for a Trial Participant

Risk Assessment

NCM reviews the daily MEDBRIDGE-generated high-risk patient list

Ongoing during recruitment

Initial Patient Contact

NCM/CHW team initiates contact after discharge to review medications and identify discrepancies

Within first week post-discharge

Ongoing Support

CHW provides monthly check-ins to monitor adherence, address barriers, and coordinate with primary care providers

3 months

Transition to Routine Care

Team facilitates handoff to the patient's primary care provider with a summary of activities and recommendations

End of 3-month intervention

Follow-up

Participants are monitored for safety and effectiveness after treatment

3 months post-discharge

What Are the Treatments Tested in This Trial?

Interventions

  • MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention

Trial Overview

The study tests a support program where a nurse case manager and community health worker help high-risk patients manage their diabetes medications for 3 months after leaving the hospital, using a computer tool to identify who needs extra help.

How Is the Trial Designed?

1

Treatment groups

Experimental Treatment

Group I: MEDBRIDGE-Guided NCM/CHW SupportExperimental Treatment1 Intervention

Find a Clinic Near You

Who Is Running the Clinical Trial?

University of Alabama at Birmingham

Lead Sponsor

Trials
1,677
Recruited
2,458,000+

Citations

MEDBRIDGE-Guided NCM/CHW Post-Discharge Support ...

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Community-Based Models for Type 2 Diabetes Care - PMC

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The Effects of a Nurse Case Manager

In on-treatment analyses, the rate reduction was strongest for patients who received the most. NCM and CHW visits (RD, −31.0; adjusted RR, 0.66; ...

CPSTF Finding and Rationale Statement - Diabetes CHW

The CPSTF recommendation is based on evidence from a systematic review of 22 studies (search period through May 2015). Studies evaluated the effectiveness of ...

MEDBRIDGE-Guided NCM/CHW Post-Discharge Support ...

Secondary outcomes include HbA1c change, diabetes-related emergency department visits, and diabetes-related hospitalizations within 3 months post-discharge, ...

The Influence of Nurse-Led Interventions on Diseases ... - PMC

Interventions led by nurses can support PWD for effective management of diabetes, which can positively improve clinical outcomes. Nurse-led ...