Core Projects
CO-IMPACT Study
A VA-funded RCT of an intervention aimed to improve patient engagement and lower risk for diabetes complications, through technology-enhanced coaching of patients along with supportive family members. The study toolkit contains information and tools that can be used by healthcare professionals, family members, or patients who are interested in helping patients’ family or friends get more involved with patients’ healthcare.
Rosland AM, Piette JD, Trivedi R, Lee A, Stoll S, Youk AO, Obrosky DS, Deverts D, Kerr EA, Heisler M. Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes: A Randomized Clinical Trial. JAMA Netw Open. 2022 Nov 1;5(11):e2237960. doi: 10.1001/jamanetworkopen.2022.37960. PMID: 36374502; PMCID: PMC9664266.
FAM-ACT Study
FAMily Support for Health ACTion (FAM-ACT) is a community health worker-delivered diabetes self-management education and support (DSMES) program for adults with type 2 diabetes and the friends and family members who support them. FAM-ACT is adds to standard DSMES by teaching family supporters how to use autonomy-supportive strategies and positive communication techniques to support the adult with diabetes in achieving and sustaining successful diabetes management. A NIH-funded trial comparing the effectiveness of FAM-ACT to traditional patient-focused DSMES is currently is being conducted In partnership with Community Health and Social Services (CHASS) Center, Inc. in Detroit, Michigan. The study is entering the analysis phase and the main study outcomes are expected in 2024.
Deverts DJ, Heisler M, Kieffer EC, Piatt GA, Valbuena F, Yabes JG, Guajardo C, Ilarraza-Montalvo D, Palmisano G, Koerbel G, Rosland AM. Comparing the effectiveness of Family Support for Health Action (FAM-ACT) with traditional community health worker-led interventions to improve adult diabetes management and outcomes: study protocol for a randomized controlled trial. Trials. 2022 Oct 3;23(1):841. doi: 10.1186/s13063-022-06764-1. PMID: 36192769; PMCID: PMC9527393.
MPowerHub
MPowerHub is a web-based platform that integrates rich real-time data from continuous glucose and activity monitors with patient-reported data about medication taking and other self-management behaviors. MPowerHub prompts users to choose behavioral goals based on their insights from interactive visualizations of their information, then make action plans to reach their goals. The MPowerHub platform currently is under development in collaboration with the Mobile Sensing + Health Institute (MOSHI) with support from the Pittsburgh Foundation and Pitt Innovation Challenge. In 2024, we will be conducting a randomized pilot trial to optimize the MPowerHub intervention protocol for adults with type 2 diabetes in preparation for a multi-site efficacy trial.
VA High Risk Investigator Network and Analytic Core
The High Risk Investigator Network and Analytic Core (the ‘High Risk Core’) within the VA Primary Care Analytic Team (PCAT) supports the VA Office of Primary Care (OPC) in building capacity for complex, high risk patient care evaluation and application development by 1) connecting a network of complex care scientific experts; 2) generating informational and methodological resources to support the conduct of complex care relevant evaluations; and 3) providing scientific and analytic expertise to national evaluation studies with potential to impact high risk patient care.
VET-PATHS
The VETeran Panel Management Tool for High-Risk Subgroups (VET-PATHS) is a web-based panel management tool designed to support proactive management of Veteran patients at high risk for hospitalization. The tool sorts high-risk patients into data-derived subgroups based on their pattern of diagnoses, and leverages EHR data-based insights to suggest high-priority, risk-reducing care actions for consideration by the primary care team. Feasibility testing of the tool is underway at VA primary care clinics. A multi-site trial in in development to assess the tool’s ability to improve the receipt of care and health outcomes of high-risk Veterans who receive care in VA Primary Care settings.
High Risk Patient Comorbidity Subgroups: Analyses and Applications
Our team, supported by VA operations partners, develops and implements innovative segmentation and machine learning methods to identify clinically-relevant subgroups of high risk patients using real-time health system data. Our findings have recently been implemented into a panel management tool available to VA clinicians that uses real-time health system data to support effective primary care management for high risk patients.
Click here to read about VA High Risk Comorbidity Subgroups Analyses.
Click here to watch our Segmenting Methods and Applications Cyberseminar.
RIVET QUERI
High-RIsk VETerans (RIVET) QUERI Program aims to advance VHA primary care ability to provide comprehensive, evidence-based care for complex, high-risk patients. RIVET will support VHA as a learning organization through data-driven priority-setting, leveraging virtual care to enhance mental and whole health, and standardizing care to reduce inefficiency and variations in care quality for high-risk patients.