Медсестра с расширенными возможностями для оказания помощи при хронических заболеваниях (EXTEND)

EXTEND participants receive 4 mobile monitoring devices to facilitate chronic disease self-management (glucometer, BP cuff, scale, accelerometer). Device data are transferred to Duke University Health System (DUHS). Participants can review data and trends within the device apps and modify self-management practices accordingly. The EXTEND group continues chronic disease care with their existing providers during the study, and are instructed at baseline to address management questions via their primary clinics' established avenues (as would be the case for any patient using mobile monitoring in clinical practice).

EXTEND patients self-manage using data they collect during the study, and continue to receive standard behavioral counseling from primary providers.

EXTEND Plus participants receive 4 mobile monitoring devices to facilitate chronic disease self-management (glucometer, BP cuff, scale, accelerometer). Device data are transferred to Duke University Health System (DUHS) for use as part of nurse-delivered intervention combining mobile monitoring, self-management support, and medication management. The intervention is administered by clinical registered nurses (RNs) from Duke Primary Care (DPC) or Duke Endocrinology. For the medication management component, RNs work with a study PharmD affiliated with the participant's clinic. The PharmD determines if medication changes are needed, and prescribes accordingly. The RNs deliver EXTEND Plus via scheduled telephone encounters throughout the 12-month intervention. The initial encounter frequency is every two weeks, but may be extended to every four weeks for patients achieving treatment goals.

The EXTEND Plus approach builds patient self-management capacity by focusing on knowledge, self-efficacy, and goal setting (using an RN-delivered, module-based approach). All material is at an 8th grade reading level. Module topics include, but are not limited to, use of self-monitoring of blood glucose (SMBG), BP monitoring, developing a diet plan, medication adherence, hypoglycemia and hypotension self-management, and self-managing insulin. In addition, this intervention component addresses diet and activity self-management during each encounter.

Change in blood sugar (glucose) attached to hemoglobin. Validated point-of-care or lab-based test.

Measure taken at clinic with standard arm cuff. Measurement is the average of two readings, on the same arm, taken 10 minutes apart.

Measure taken at clinic with standard arm cuff. Measurement is the average of two readings, on the same arm, taken 10 minutes apart.

Measurement taken with lab scale, when patient is lightly clothed, shoes off.

Measure of diabetes distress and burden using the Diabetes Distress Scale (DDS): 17 items, Scale 1-6. Scoring: Average. Higher score indicates higher distress level.

Measure of diabetes self-care. Diabetes Self-Management Questionnaire (DSMQ): 16 items, Scale 0-3. Scoring: Sum and transform to fall between 0-10. Higher score indicates more effective self-care.

Measure of diabetes self-efficacy and capacity. Perceived Competence Scale (PCS): 4 items, Scale 1-7. Scoring: average (1-7) Higher score indicates greater self-efficacy.

Validated self-report measure using Voils' medication non-adherence measure.

Voils

1. Full name: Voils Medication Nonadherence Measure
2. Construct: assesses how often a patient misses their prescribed medication and why
3. Scale range: 1-5 (the scale consists of 6 likert scale items ranging from 1=None of the time to 5=Every time. The total score is obtained by taking the mean of the items)
4. Higher scores indicate greater medication non-adherence.
5. There are no subscales.

Diabetes Knowledge Questionnaire (DKQ) is a 24-item validated measure.

Diabetes Knowledge

1. Full name: Diabetes Knowledge Questionnaire
2. Construct: assesses diabetes knowledge
3. Scale range: 0-24 (the scale consists of 24 yes-no items that assess diabetes knowledge. One point is given for each item answered correctly.)
4. Greater scores indicate greater knowledge of diabetes
5. There are no subscales.