Integrating New Skills Into Diabetes Education With CGM

This study will assess the preliminary effectiveness of a continuous glucose monitor (CGM) integration program ("intervention") in a 6-week randomized pilot study among 144 older adults with diabetes using insulin at least once daily. The CGM integration program (48 participants) will be compared to two versions of usual care: 1) one-time clinic-based CGM training (Comparator 1; 48 participants) and 2) self-directed CGM training (Comparator 2; 48 participants). Following a screening visit and baseline data collection, participants will be randomized to one of the three groups in a 1:1:1 ratio by computer-generated sequence. All participants will be provided with 6-week supply of unblinded CGM sensors. Participants who are randomized to the intervention group will attend three closed group sessions over 4 weeks. Session 1 (Day 1) will be held in-person, where participants will receive technical training related to CGM sensor insertion, transmitter pairing, and receiver operation. Session 2 (Day 14) will be held virtually and will consist of training in how to read and understand CGM data, customize target ranges, alerts, and alarms, export and review historical data, and share CGM data with care partners. Session 3 (Day 28) will also be held virtually and will consist of training in strategies to utilize CGM for improved safety and quality of life. Between each session, participants will be remotely assessed for CGM use and glucose trends. Based on these remote assessments, participants may receive 1-2 additional individualized training sessions to review CGM technical skills, as well as data and self-management strategies associated with CGM use. Participants randomized to the one-time clinic-based CGM training group (Comparator 1) will complete a one-hour visit with a clinic-based educator on Day 1 of the trial. This group will be provided with basic CGM training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period. Participants randomized to the self-directed CGM training (Comparator 2) will be provided with a comprehensive informational pamphlet about CGM on Day 1 of the trial. They will also be provided with a list of online resources for CGM self-training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period. At the end of the 6-week trial, all participants will provide primary endpoint data related to continuous wear-time. In addition, secondary patient-reported outcomes and glycemic metrics will be assessed, including use of the CGM device at 6 weeks. We will conduct semi-structured interviews with a subset of purposively sampled participants (up to 20) and their care partners (up to 10) after their final endpoint visit to probe effective aspects of the intervention, challenges, struggles, and needs that were not addressed by the intervention, and strategies to improve the accessibility, acceptability, and effectiveness of the intervention for future older adults. We will conduct an extension study in which we evaluate the following metrics at 3- and 6-months post-intervention: 1) CGM prescribing patterns post-study, including the proportion of participants with a CGM order at 3 and 6 months after study endpoint; 2) Clinical and patient-reported outcomes, such as glycemic indicators, severe hypoglycemia, device satisfaction (if applicable), barriers to sustained CGM access, integration of CGM into care and self-management, and unmet needs; 3) provider documentation of clinical rationale, perceived benefits, and barriers to CGM use across diverse care settings (internal medicine, family medicine, geriatrics, endocrinology). Lastly, this study will involve a care partner sub-study. The aim of the care partner sub-study is to understand how the intervention improves or changes the knowledge and attitudes around CGM and diabetes management in care partners of older adults with diabetes. Consented care partners will be invited to attend any session their partner participant is assigned to. Care partners will be asked to complete care partner-specific questionnaires at baseline, at the end of the 6-week trial, and at 3- and 6-months post-intervention.