Post-Discharge Support for Type 2 Diabetes
(MEDBRIDGE Trial)
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.12345Why 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?
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
Exclusion Criteria
Timeline for a Trial Participant
Risk Assessment
NCM reviews the daily MEDBRIDGE-generated high-risk patient list
Initial Patient Contact
NCM/CHW team initiates contact after discharge to review medications and identify discrepancies
Ongoing Support
CHW provides monthly check-ins to monitor adherence, address barriers, and coordinate with primary care providers
Transition to Routine Care
Team facilitates handoff to the patient's primary care provider with a summary of activities and recommendations
Follow-up
Participants are monitored for safety and effectiveness after treatment
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
High-risk patients with type 2 diabetes identified by the MEDBRIDGE risk stratification tool receive a 3-month post-discharge support intervention delivered by a nurse case manager (NCM) and community health worker (CHW) team.
Find a Clinic Near You
Who Is Running the Clinical Trial?
University of Alabama at Birmingham
Lead Sponsor
Citations
MEDBRIDGE-Guided NCM/CHW Post-Discharge Support ...
This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes ...
Community-Based Models for Type 2 Diabetes Care - PMC
Effectiveness: CHW-based interventions demonstrated meaningful improvements in clinical and behavioral outcomes. The Pakistan CCM model ...
New diabetes clinical trial: MEDBRIDGE-Guided NCM/CHW ...
This new Health Research Consortium is to decrease the disparities of Obesity and Type 2 Diabetes in Medically Underserved Communities. Home of ...
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; ...
5.
thecommunityguide.org
thecommunityguide.org/pages/tffrs-diabetes-prevention-interventions-engaging-community-health-workers.htmlCPSTF 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 ...
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