Studying interventions to help type 2 diabetes patients avoid hospitalizations

Type 2 diabetes mellitus, also known as T2DM, is a complex health condition that affects over 37 million Americans each year. 

Diabetes self-management guidelines encourage patients living with type 2 diabetes mellitus to seek ongoing medical care, take prescribed medications as directed, follow a strict diabetes-friendly diet and exercise regularly to keep the disease under control.

Yet, close to 8 million patients are admitted to the hospital each year with serious diabetes complications.

These complications are often the result of unmet health-related social needs, also known as social determinants of health, like inadequate housing, low income, limited availability of healthy food, insufficient access to health care, lack of social support and low health literacy.

In addition to these social determinants of health, many type 2 diabetes mellitus patients struggle with personal challenges that hinder their engagement with the health care process such as coping with a high burden of illness, believing they’re unable to take care of themselves, feeling stigmatized because of their disease and more.

These challenges can have negative emotional and psychological impacts, leading to poor glucose control and, ultimately, medical complications requiring hospitalization.

To reduce social determinants of health-related diabetes complications and associated hospitalizations, University of Michigan Health professor of physical medicine and rehabilitation, Noelle Carlozzi, Ph.D., is collaborating with Suzanne Mitchell, M.D., at the University of Massachusetts Chan Medical School on a funded study to evaluate an intervention designed to identify, prioritize and help address these needs.

The project, titled The Re-Engineered Discharge for Diabetes Care Transitions, or REDD-CAT2: Screening and Addressing Social Determinants of Health Needs at Hospital Discharge, builds on the research team’s previous work.

“Understanding patients’ unmet social needs is critical for providing optimal patient care and minimizing hospital readmission risk for individuals with type 2 diabetes mellitus,” said Carlozzi.

The REDD-CAT2 project combines two innovative intervention components that were developed through prior NIH-funded projects including a comprehensive screening tool to efficiently capture and create a personalized profile of unmet social determinants of health-related needs for type 2 diabetes mellitus patients at risk of poor health outcomes, and an evidence-based patient navigation protocol, known as PROJECT REDD, that uses a patient navigator to assess and prioritize unique social needs at the hospital bedside and provide post-discharge support over a 90-day care transition period to help patients gain access to the resources they need to stay healthy.

The REDD-CAT2 intervention, a combination of the REDD-CAT plus PROJECT REDD, will be implemented during the hospital discharge process, an especially vulnerable time for type 2 diabetes mellitus patients who may be recovering from illness and coping with frail health.

The research team will compare REDD-CAT2 to care as usual to examine the intervention’s impact on risk of hospital readmission.

It’ll also be used to generate a unique type 2 diabetes mellitus patient risk profile algorithm for future work.

Funding/disclosures: The Re-Engineered Discharge for Diabetes Care Transitions, or REDD-CAT2: Screening and Addressing Social Determinants of Health Needs at Hospital Discharge; National Institute of Nursing Research (NINR R01 NR021826) Principal Investigator: S.E. Mitchell

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