MPowerHub
MPowerHub is a mobile phone application (app) 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 app was developed in collaboration with the Mobile Sensing + Health Institute (MOSHI) with support from the Pittsburgh Foundation and Pitt Innovation Challenge. In 2024, we conducted a study to optimize the MPowerHub app and intervention protocol for adults with type 2 diabetes. This year, we have launched our pilot randomized controlled trial to assess protocol feasibility, accessibility, and engagement and examine self-management behavior change and glycemic change for adults with type 2 diabetes.
Bober, T., Garvin S., Krall, J. Zupa, M., Low, C.; Rosland, AM. How Adults with Diabetes use New Technologies to Support Diabetes Self-Management: A Mixed Methods Study. JMIR Diabetes, 2025.
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. Feasibility testing of the tool was completed with 6 VA primary care clinics. The tool was found to be useful and resulted in documented clinical impacts. A multi-site trial is 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.
Effective Virtual Care for Adults with Diabetes Through Tailored Modalities
Nearly 20% of the more than 30 million Americans with type 2 diabetes face geographic or transportation barriers to diabetes specialty care. Telemedicine has the potential to help more patients access this care, but evidence suggests telemedicine is less effective for adults with type 2 diabetes which is complex, including those who use multiple daily injections of insulin and have multiple comorbid conditions. The objective of this project is to develop an intervention to deliver high-quality virtual diabetes specialty care to adults with complex type 2 diabetes, thereby improving effectiveness of care for patients who rely on telemedicine.
Bober T, Rollman BL, Handler S, Watson A, Nelson LA, Faieta J, Rosland AM. Digital Health Readiness: Making Digital Health Care More Inclusive. JMIR Mhealth Uhealth. 2024 Oct 9;12:e58035.
Zupa MF, Vimalananda VG, Rothenberger SD, Lin JY, Ng JM, McCoy RG, Rosland AM. Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes. JAMA Netw Open. 2023;6(12):e2346305.
Zupa MF, Alexopoulos AS, Esteve L, Rosland AM. Specialist Perspectives on Delivering High-Quality Telemedicine for Diabetes: A Mixed Methods Survey Study. Journal of the Endocrine Society, 2023;7(5):bvad039. Published online 2023 Mar 20.
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.
FAM-ACT Study
Challenges to controlling risk factors put millions of U.S. adults at high risk of disabling complications from chronic conditions such as diabetes, heart disease, and asthma. 75% of adults with chronic health conditions reach out to an unpaid family member or friend for ongoing help with managing their condition, yet few interventions directly engage patients' supportive family members in their healthcare. Our center researches and tests ways to mobilize the power of patients’ social networks to support adults with chronic condition management challenges.
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 enhances 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 was completed in partnership with Community Health and Social Services (CHASS) Center, Inc. in Detroit, Michigan.
Deverts DJ, Zupa MF, Kieffer EC, Gonzalez S, Guajardo C, Valbuena F, Piatt GA, Yabes JG, Lalama C, Heisler M, Rosland AM. Patient and family engagement in culturally-tailored diabetes self-management education in a Hispanic community. Patient Educ Couns. 2025 Jan 17;134:108669. Epub ahead of print.
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.
Zupa MF, Perez S, Palmisano G, Kieffer EC, Piatt GA, Valbuena FM, Deverts DJ, Yabes JG, Heisler M, Rosland AM. Changes in self-management during the COVID-19 pandemic among adults with type 2 diabetes at a federally qualified health center. Journal of Immigrant and Minority Health. 2022 Oct;24(5):1375-8.
Click here to learn more about the FAM-ACT Study.
VA High Risk Investigator Network and Analytic Core
The 5% most complex patients account for 50% of healthcare system costs and hospitalizations, and many complex patients require intensive care coordination with multiple specialty care services to improve their health outcomes. Tools available to Primary Care teams can identify patients at high risk for hospitalization, but care teams still struggle to determine what high-risk patients’ care needs are, how to prioritize resources among high-risk patients, and where patients’ care coordination should be centered. Our center works to develop and evaluate new approaches to caring for healthcare systems’ most complex and high-risk patients. A major focus is on creating data-driven tools that can proactively and efficiently tailor care plans to match patient needs.
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.
To learn more about The High Risk Investigator Network and Analytic Core, please email us at VHAPCATHighRisk@va.gov
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) 2.0 QUERI Program aims to improve access to high-quality primary care for Veterans at high risk for adverse health outcomes. RIVET 2.0 will support VHA as a learning organization through data-driven priority-setting, by leveraging virtual care to enhance mental health and extended primary care team members for transitional care, and standardizing care to reduce inefficiency and variations in care quality for high-risk patients. The RIVET 2.0 QUERI program builds upon the success of of the first iteration (RIVET 1.0) through new partnerships, evidence-based practices, and implementation strategies to maximize our impact on high-risk Veteran primary care.
For more information about RIVET 1.0 QUERI Program: Jimenez, E.E., Rosland, AM., Stockdale, S.E. Reddy, Ashok, Wong, Michelle S., Torrence, Natasha, Huynh, Alexis, Chang, Evelyn T. Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial. Implement Sci Commun 5, 75 (2024).
For more information about RIVET 2.0 QUERI Program: RIVET 2.0 Executive Summary.