Diabetes Rescue, Engagement and Management (D-REM): rationale and design of a pragmatic clinical trial of a community paramedicine programme to improve diabetes care.

INTRODUCTION: Diabetes is one of the most common serious chronic health conditions in the USA. People living with diabetes face multiple barriers to optimal diabetes care, including gaps in access to medical care and self-management education, diabetes distress, and high burden of treatment. Community paramedics (CPs) are uniquely positioned to support multidisciplinary care for patients with diabetes by delivering focused diabetes self-management education and support and bridging the gaps between patients and the clinical and community resources they need to live well with their disease. METHODS AND ANALYSIS: We will conduct a pragmatic single-arm prospective trial of a CP-led Diabetes Rescue, Engagement and Management (D-REM) programme that seeks to reduce diabetes distress. We will enrol 70 adults (≥18 years) with diabetes who have haemoglobin A1c (HbA1c)≥9.0%, experienced an emergency department (ED) visit or hospitalisation for any cause within the prior 6 months, and reside in areas with available CP support in Southeast Minnesota (Olmsted, Freeborn and Mower counties) and Northwest Wisconsin (Barron, Rusk and Dunn counties). Participants will be identified using Mayo Clinic electronic health records, contacted for consent and enrolled into the D-REM programme. Visit frequency will be individualised for each patient, but will be an average of four CP visits over the course of approximately 1 month. Outcomes will be change in diabetes distress (primary outcome), confidence in diabetes self-management, health-related quality of life, self-reported hypoglycaemia and hyperglycaemia, HbA1c, ED visits and hospitalisations. Outcomes will be assessed on enrolment, programme completion and 3 months after programme completion. ETHICS AND DISSEMINATION: The study was approved by Mayo Clinic Institutional Review Board. Findings will be disseminated through peer-reviewed publications and presentations. If demonstrated to be successful, this model of care can be implemented across diverse settings and populations to support patients living with diabetes. TRIAL REGISTRATION NUMBER: NCT04385758.

Development and Implementation of a Community Paramedicine Program in Rural United States.

INTRODUCTION: Community paramedicine (CP) is an innovative care model focused on medical management for patients suffering from chronic diseases or other conditions that result in over-utilization of healthcare services. Despite their value, CP care models are not widely used in United States healthcare settings. More research is needed to understand the feasibility and effectiveness of implementing CP programs. Our objective was to develop a CP program to better meet the needs of complex, high-utilizer patients in a rural setting. METHODS: We conducted an observational descriptive case series in a community, 25-bed, critical access hospital and primary care clinic in a rural Wisconsin county. Multiple stakeholders from the local health system and associated ambulance service were active participants in program development and implementation. Eligible patients receiving the intervention were identified as complex or high need by a referring physician. Primary outcomes included measures of emergency department, hospital, and clinic utilization. Secondary measures included provider and patient satisfaction. RESULTS: We characterized 32 unique patients as high utilizers requiring assistance in medical management. These patients were enrolled into the program and categorized as high utilizers requiring assistance in medical management. The median age was 76 years, and 68.8% were female. After six months, we found a statistically significant decline in patient utilization for primary care (53.3%, p = .006) and ED visits (59.3%, p = .007), but not for hospitalizations (60%, p = .13, non-significant (NS), compared to the six months preceding enrollment. Overall, the total number of healthcare contacts was increased after implementation (623 before vs 790 after, + 167, +26.8%). Implementation of the CP program resulted in increased overall use of local healthcare resources in patients referred by physicians as high utilizers. CONCLUSION: The implementation of an in-home CP program targeting high users of healthcare resources resulted in a decrease in utilization in the hospital, ED, and primary care settings; however, it was balanced and exceeded by the number of CP visits. CP programs align well with population health strategies and could be better leveraged to fill gaps in care and promote appropriate access to healthcare services. Further study is required to determine whether the shift in type of healthcare access reduces or increases cost.