FQHC Intervention for CGM Uptake in Adults with T1D

Low-income adults with type 1 diabetes (T1D) face a high risk for life-threatening, acute complications with increased rates of related emergency department visits, hospitalizations, and death. Use of continuous glucose monitoring (CGM) helps mitigate T1D complications. Yet, low-income adults with T1D have exceptionally low levels of CGM use. This reflects social determinants of health (SDOH), as framed by the Socio-Ecological Model (SEM). Following SEM, healthcare is a main driver in limiting access to CGM. With a severe shortage of endocrinologists, primary care providers (PCPs), including Federally Qualified Health Center (FQHC) PCPs, are increasingly managing T1D. Although PCPs are filling a gap in T1D care, they often lack proficiency in integrating CGM into clinical practice with most reporting inadequate confidence in using CGM and insulin titration. At FQHCs (90% low-income patient population), CGM prescriptions are often infrequent for patients with T1D although it is an American Diabetes Association standard of care. To foster uptake of CGM in low-income adults, we will partner with FQHCs in conducting a 4-year, mixed-methods, feasibility study with a pilot randomized controlled trial (RCT). FQHC adult patients with T1D and at or below the federal poverty level will be sampled. Informed by SEM, the intervention targets the individual, family/social networks, and healthcare provider levels. The individual level of the intervention fosters acquisition of information, motivation, and behavioral skills for CGM uptake through sessions led by a RN diabetes educator and peer educator, respectively. The family/social networks level leverages social support with a family member co-attending the 4-week RN sessions and participant engagement with a peer educator over six months. The provider level provides rigorous clinical support for CGM via Project ECHO. In study phase 1 (Aim 1), the intervention be refined, informed by stakeholder qualitative findings. Study deployment will be planned with randomization of 9 FQHC sites to deliver the intervention (n=6) or control (n=5) conditions with a total enrollment goal of 30 adults with T1D. Project ECHO programs will be delivered to intervention (T1D Care + CGM) and control (T1D Care) site providers, respectively. In study phase 2 (Aim 2), feasibility of the study protocol (e.g., recruitment and retention yields, data collection, intervention implementation, among others) will be assessed routinely. In phase 2 (Aim 3), significant intervention signals in terms of physiological (A1C and CGM metrics), psychosocial (e.g., quality of life, family support, physician trust), and behavioral (CGM adherence) outcomes from baseline to 3- and 6-months post-baseline will be assessed across the sample, including analyses for racial/ethnic subgroups with >12 participants. Findings will guide a fully powered, multi-site RCT to inform a FQHC model of care for CGM uptake in adults with T1D.