Reducing diabetes disparities through the implementation of a community health worker-led diabetes self-management education program

Patients' Perspectives on the Acceptability and Effectiveness of a Community Health Worker-Led Intervention to Increase Chronic Kidney Disease Knowledge and Screening among Underserved Latine Adults: The CARE 2.0 Study

In the United States, Chronic Kidney Disease (CKD) affects approximately 1 in 7 adults. Despite its significant impact, CKD awareness, education, and screening are often lacking among underserved Latine populations, leading to poorer health outcomes and higher mortality rates. Various studies highlight the crucial role of Community Health Workers (CHWs) in improving health outcomes within minority communities both domestically and globally. However, there remains a gap in research on the acceptance and effectiveness of CHW-led interventions targeting CKD. This prospective intervention study employed a pre-post quasi-experimental design to evaluate a CHW-led educational program aimed at enhancing CKD knowledge, screening, and monitoring among Latines with low health literacy and English proficiency. CHWs utilized a culturally tailored CKD Flipchart, and 100 underserved patients received the intervention. Feedback from 85 participants who completed post-intervention surveys indicated high satisfaction with the program's relevance and the professionalism of the CHWs. Importantly, 85% expressed a positive intention to seek kidney care following the intervention. Preliminary analysis of medical records before and after the intervention showed improvements in glycemic control (median change = -18.0, p = 0.014) and triglyceride levels (median change = -29.0, p = 0.035), suggesting the program's effectiveness in managing CKD risk factors. These findings highlight the potential of CHW-led interventions to reduce kidney health disparities among underserved communities.

Evaluating the implementation of group empowerment and training (GREAT) for diabetes in South Africa: convergent mixed methods

OBJECTIVE

Type 2 diabetes is a leading contributor to the burden of disease in South Africa. Primary care is struggling to support self-management and lifestyle change. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the implementation of GREAT for diabetes.

DESIGN

A convergent mixed-methods study evaluated a range of implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, reach and cost.

SETTING

Ten primary care facilities from a district in all nine provinces of South Africa.

PARTICIPANTS

Descriptive exploratory individual semistructured interviews were conducted with 34 key stakeholders from national policy-makers to primary care providers. Three focus group interviews were held with 35 patients.

RESULTS

The National Department of Health saw GREAT as an acceptable and appropriate intervention, but only five of the nine provinces adopted GREAT. District-level and facility-level managers also saw GREAT as an acceptable and appropriate intervention. Factors related to feasibility included physical space, sufficient staff numbers, availability of resource materials, the health information system, adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems, leadership from local managers and the whole clinical team) and inclusion in systems for quality improvement. No major changes were made to the design of GREAT and fidelity to the session content ranged from 66% to 94%. Incremental costs were US$494 per facility. Due to disruption from the COVID-19 pandemic, only 14 facilities implemented and reached 588 patients at the time of evaluation.

CONCLUSION

Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country setting. The findings informed the design of a programme theory using a health system framework. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented.

QUESTION

This study focused on evaluating how to implement GREAT for type 2 diabetes in primary care and to take it to scale in South Africa.

FINDING

The findings led to a programme theory on how to successfully implement GREAT for diabetes in the South African context.

MEANING

The study demonstrates relevant contextual factors that need to be considered in the implementation of group diabetes education programme in a middle-income country.

Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review

OBJECTIVE

We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented.

DESIGN

We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance.

DATA SOURCES

We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022.

ELIGIBILITY CRITERIA

We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described.

DATA EXTRACTION AND SYNTHESIS

The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency.

RESULTS

Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes.

CONCLUSION

This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations.

PROSPERO REGISTRATION NUMBER

CRD42022369208.

Cardiovascular Disease and Stroke-Focused Competency Assessment Tools for Community Health Workers in the United States: A Scoping Review

Cardiovascular disease (CVD) and stroke are major contributors to chronic disease burden in the United States. Despite the high prevalence of stroke, 90% of all stroke events are preventable and can be attributed to seven key modifiable risk factors (MRFs)-high blood pressure (BP), high cholesterol, diabetes mellitus (DM), smoking, obesity, unhealthy diet, and physical inactivity. In the United States, stroke prevention interventions led by community health workers (CHWs) have been proven to be highly effective in preventing the onset of MRFs. We conducted a scoping review of the competency assessment methods used in CVD and stroke-focused CHW training programs. We searched six online databases: PubMed, Cochrane, CINAHL, Embase, Web of Science, and HaPI, from all available years until January 2021. Of the 1,774 initial articles found, we identified 30 eligible articles to be included in the review. Nine of these studies used previously validated instruments, whereas the remaining 21 studies used tools from the training curriculum or independently developed instruments. Only five of these validated tools reported psychometric properties; none of them were designed for the CHW population. Our scoping review of literature revealed that CHW-specific competency assessment methods were limited, with few or no domain-referenced tools on CVD or stroke risk factors that complied with established measurement standards. We conclude that there is an urgent need for the development of a comprehensive and valid assessment instrument in CVD and stroke prevention to evaluate CHW performance and optimize their credibility, representing important first steps toward integrating CHWs into health care systems.

Self-management education for children with epilepsy and their caregivers. A scoping review

Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.

Barriers and Strategies to Operationalize Medicaid Reimbursement for CHW Services in the State of Minnesota: a Case Study

Integrated medical and social care via community health worker (CHW) services is a growing area of interest, particularly among health care organizations that offer care for underserved populations. Establishing Medicaid reimbursement for CHW services is only one step to improve access to CHW services. Minnesota is one of 21 states that authorize Medicaid payment for CHW services. Despite available Medicaid reimbursement for CHW services since 2007, the actual experience of many Minnesota health care organizations in obtaining reimbursement for CHW services has been challenging due to barriers at multiple levels (e.g., clarifying and operationalizing regulation, navigating complexity of billing, building organizational capacity to reach key stakeholders at state agencies and health plans). This paper provides an overview of the barriers and strategies to operationalize Medicaid reimbursement for CHW services in the state of Minnesota, through the experience of a CHW service and technical assistance provider. Based on lessons learned in Minnesota, recommendations are made to other states, payers, and organizations as they navigate processes to operationalize Medicaid payment for CHW services.

Participant engagement in a community health worker-delivered intervention and type 2 diabetes clinical outcomes: a quasiexperimental study in MexicanAmericans

OBJECTIVES

This study helps to fill the existing research gap related to participant engagement in behavioural interventions and diabetes management. We examined type 2 diabetes control over time among Mexican Americans by level of engagement in a chronic care management (CCM) program that included community health worker (CHW)-delivered multilevel interventions. The programme complemented clinical care and promoted behaviour changes to improve diabetes self-management.

DESIGN

Quasiexperimental study.

SETTING

The study was implemented in the Rio Grande Valley region in the USA. Recruitment was conducted in clinics and community events. All other visits were provided in participant homes and community locations.

PARTICIPANTS

5649 adults (aged ≥18 years) with poorly controlled type 2 diabetes who enrolled in a community-delivered CCM programme between September 2013 and 2018.

INTERVENTIONS

The intervention comprised two components: CHW home visits conducted every 3 months and diabetes self-management education (DSME) classes provided in community locations.

PRIMARY OUTCOME MEASURES

The primary outcome was haemoglobin A1c (HbA1c) measured at baseline every 3 months for up to 24 months. We first examined changes in HbA1c levels over time. The number of completed CHW and DSME encounters was used to classify participants into engagement groups-high engagement defined as ≥10 encounters (n=2952); low engagement defined as 1-9 encounters (n=2697). We used univariable and multivariable longitudinal linear regression models with a generalised estimating equation method. We tested interactions between engagement groups and time.

RESULTS

Participants' mean HbA1c decreased from 10.20% at baseline to 8.93% (p<0.0001) at 3 months, remaining stable thereafter. Changes in HbA1c were statistically different between the engagement groups. High engagement participants had lower HbA1c levels over the first 15 months of the follow-up period compared with low engagement participants, as compared at 3 months (-0.44%, 95% CI -0.57% to -0.31%; p<0.0001), 6 months (-0.31%, 95% CI -0.43% to -0.14%; p<0.0001), 9 months (-0.27%, 95% CI -0.42% to -0.13%; p=0.0001), 12 months (-0.23%, 95% CI -0.37% to -0.08%; p=0.0025) and 15 months (-0.32%, 95% CI -0.54% to -0.10%; p=0.0040). At months 18, 21 and 24, the HbA1c differences were not statistically significant (18 months: -0.34%, 95% CI -0.77% to 0.08%; p=0.1086; 21 months: -0.22%, 95% CI -1.00% to 0.56%; p=0.5721; 24 months: -0.42%, 95% CI -1.38% to 0.55%; p=0.3966).

CONCLUSIONS

Higher engagement in the CCM programme delivered by CHWs and coordinated with clinical care was associated with beneficial improvements in type 2 diabetes control, but both engagement groups showed strong improvements.

A Community Health Worker-Led mHealth-Enabled Diabetes Self-Management Education and Support Intervention in Rural Latino Adults: Single-Arm Feasibility Trial (Preprint)

Background

Latinos living in rural South Texas have a higher prevalence of diabetes, but their access to diabetes self-management education and support (DSMES) is limited.

Objective

We aimed to test the feasibility of a community health worker-led, mobile health (mHealth)-based DSMES intervention to reduce disparities in accessing DSMES in underserved rural Latino residents in South Texas.

Methods

This 12-week, single-arm, pre-post trial was delivered by trained community health workers to 15 adults with type 2 diabetes. The intervention consisted of digital diabetes education, self-monitoring, a cloud-based connected platform, and community health worker support. Feasibility was evaluated as retention, actual intervention use, program satisfaction, and barriers to implementation. We also explored the intervention’s effect on weight loss and hemoglobin A_1c (HbA_1c).

Results

All 15 participants were Latino (mean age 61.87 years, SD 10.67; 9/15 female, 60%). The retention rate at posttest was 14 of 15 (93%). On average, the participants completed 37 of 42 (88%) digital diabetes education lessons with 8 participants completing all lessons. Participants spent 81/91 days (89%) step tracking, 71/91 days (78%) food logging, 43/91 days (47%) blood glucose self-monitoring, and 74/91 days (81%) weight self-monitoring. The level of program satisfaction was high. On average, participants lost 3.5 (SD 3.2) kg of body weight (P=.001), while HbA_1c level remained unchanged from baseline (6.91%, SD 1.28%) to posttest (7.04%, SD 1.66%; P=.668).

Conclusions

A community health worker-led mHealth-based intervention was feasible and acceptable to improve access to DSMES services for Latino adults living in rural communities. Future randomized controlled trials are needed to test intervention efficacy on weight loss and glycemic control.

Barriers and enablers to health service access amongst people with diabetes: An exploration of the perceptions of health care staff in regional Australia

Healthcare staff are in a unique position of understanding client experiences, physiological impacts of client behaviour, the local healthcare system and the physical environment in which the services operate. Their perspectives may provide insights into the feasibility and effectiveness of existing models of diabetes care and suggestions for improvements to models of care (MoC). The objective of this qualitative study was to explore the experiences of healthcare staff delivering care for people with diabetes at the request of an existing healthcare service. Semi-structured interviews were conducted with 21 healthcare staff from three community health centres in one region of Victoria, Australia, in 2018. Interviews were audio-recorded and transcribed verbatim. Data were subject to qualitative content analysis and, subsequently, emerging themes were classified at individual, relationship, community and societal levels of the social-ecological model (SEM). Perceived barriers of access to health services using the current MoC included a lack of public transport, low socioeconomic status, job insecurity (resulting in an inability to take time away from work) and inflexible appointment times, all of which negatively impact diabetes management. Perceived enablers included having a co-located, multidisciplinary team, a holistic approach to diabetes management and motivation resulting from improvement in diabetes-related health outcomes. The findings indicate that there is potential to improve the service in this region by adopting a more integrated, team-focused and accessible MoC.

Patient Centered Studies Focused on Type 2 Diabetes Management, Education, and Family Support: A Scoping Review

BACKGROUND

Although a large amount of research has been conducted in diabetes management, many of the articles do not focus on patient-centered questions and concerns. To address this shortcoming, patients and various other stakeholders from three northern Mississippi communities co-created research questions focused on Type 2 diabetes management.

OBJECTIVE

To identify the diabetes management literature pertaining to each of the six patient-developed research questions from March 2010 to July 2020.

METHODS

A scoping review was conducted via PubMed to identify research articles from March 2010 to July 2020 focused on patient-centered Type 2 diabetes studies relevant to the six research questions.

RESULTS

A total of 1,414 studies were identified via the search strategy and 34 were included for qualitative analysis following article exclusion. For one of the research questions, there were no articles included. For the remaining research questions, the number of articles identified ranged from two to eleven. After analysis of the included articles, it was found that these questions either lacked extensive data or had not been implemented in the practice of diabetes management.

CONCLUSION

Additional research is warranted for three of the five questions, as current evidence is either lacking or contradictory. In the remaining two questions, it seems that adequate current research exists to warrant transitioning to implementation focused studies wherein data may be generated to improve sustainability and scaling of current programming.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative

BACKGROUND

A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes.

METHODS

The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%.

DISCUSSION

Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

The Role of Health Informatics in Facilitating Communication Strategies for Community Health Workers in Clinical Settings: A Scoping Review

BACKGROUND

Community health workers (CHWs) have been identified as effective members of health care teams in improving health outcomes and reducing health disparities, especially among racial and ethnic minorities. There is a growing interest in integrating CHWs into clinical settings using health informatics-based strategies to help provide coordinated patient care and foster health-promoting behaviors.

OBJECTIVE

In this scoping review, we outline health informatics-based strategies for CHW-provider communication that aim to improve integration of CHWs into clinical settings.

DESIGN

A scoping review was conducted.

ELIGIBILITY CRITERIA

US-based sources between 2013 and 2018 were eligible.

STUDY SELECTION

Literature was identified through PubMed and Google queries and hand searching key reference lists. Articles were screened by title, abstract, and then full-text.

MAIN OUTCOME MEASURES

Health informatics-based strategies for CHW-provider communication and their impacts on patient care were documented and analyzed.

RESULTS

Thirty-one articles discussed health informatics-based strategies for CHW-provider communication and/or integration of CHWs into clinical settings. These strategies include direct CHW documentation of patient encounters in electronic health records (EHRs) and other Web-based applications. The technologies were used to document patient encounters and patient barriers to health care providers but were additionally used for secure messaging and referral systems. These strategies were found to meet the needs of providers and CHWs while facilitating CHW-provider communication, CHW integration, and coordinated care.

CONCLUSIONS

Health informatics-based strategies for CHW-provider communication are important for facilitating CHW integration and potentially improving patient outcomes and improving disparities among minority populations. This integration can support the development of future disease prevention programs and health care policies in which CHWs are an established part of the public health workforce. However, further investigation must be done on overcoming implementation challenges (eg, lack of time or funding), especially in smaller resource-challenged community-based clinics that serve minority patients.

Patient Engagement in Type 2 Diabetes: A Collaborative Community Health Initiative

Purpose The purpose of this study was to describe the effects of an innovative rural community-based, diabetes self-management education and support (DSMES) program on patient behaviors and outcomes. Methods A 12-month pre-post study design with physiological data collection at program initiation, 16 weeks, and 6 and 12 months postenrollment was used for program assessment. The program consisted of an American Diabetes Association-accredited curriculum provided by the hospital and interfaced with a YMCA curriculum promoting lifestyle change. The 28-session program was delivered over a 1-year period. Results The sample size was 115. Participants were primarily white and female, with a mean age of 57 years. Mean body mass index (BMI) at program initiation was 37; mean A1C was 8.5 (69.4 mmol/mol). Significant reductions were obtained in weight, BMI (at 16 weeks), and A1C (at 6 months); these reductions were sustained at 12 months. Medication intake was significantly reduced, and diabetes-related emergency department visits were below national averages. Conclusions Results support the positive impact of a year-long, community-based, healthy behavior, DSMES program on health outcomes and overall costs of care delivery in the rural setting.

Role of community health workers in type 2 diabetes mellitus self-management: A scoping review

BACKGROUND

Globally the number of people with Type 2 diabetes mellitus (T2DM) has risen significantly over the last few decades. Aligned to this is a growing use of community health workers (CHWs) to deliver T2DM self-management support with good clinical outcomes especially in High Income Countries (HIC). Evidence and lessons from these interventions can be useful for Low- and Middle-Income countries (LMICs) such as South Africa that are experiencing a marked increase in T2DM prevalence.

OBJECTIVES

This study aimed to examine how CHW have been utilized to support T2DM self-management globally, their preparation for and supervision to perform their functions.

METHOD

The review was guided by a stepwise approach outlined in the framework for scoping reviews developed by Arksey and O'Malley. Peer reviewed scientific and grey literature was searched using a string of keywords, selecting English full-text articles published between 2000 and 2015. Articles were selected using inclusion criteria, charted and content analyzed.

RESULTS

1008 studies were identified of which 54 full text articles were selected. Most (53) of the selected studies were in HIC and targeted mostly minority populations in low resource settings. CHWs were mostly deployed to provide education, support, and advocacy. Structured curriculum based education was the most frequently reported service provided by CHWs to support T2DM self-management. Support services included informational, emotional, appraisal and instrumental support. Models of CHW care included facility linked nurse-led CHW coordination, facility-linked CHW led coordination and standalone CHW interventions without facility interaction.

CONCLUSION

CHWs play several roles in T2DM self-management, including structured education, ongoing support and health system advocacy. Preparing and coordinating CHWs for these roles is crucial and needs further research and strengthening.

Integrating Undergraduate Patient Partners into Diabetes self-management education: Evaluating a free clinic pilot program for the Underserved

BACKGROUND

Diabetes self-management education (DSME) improves glycemic control and health outcomes in patients with diabetes.

OBJECTIVE

A process evaluation of a two-year pilot intervention examined the feasibility and acceptability of undergraduate volunteers as Patient Partners to foster DSME participation among the underserved.Design setting, and participants. In the setting of a student-run free clinic, 22 patients enrolled in DSME were paired with 16 undergraduate volunteers. During the DSME courses, Patient Partners assisted patients during classes, called patients weekly, and accompanied patients to clinic appointments.Key process evaluation results. Average attendance at DSME classes was 79.4% and 94.7% for patients and Patient Partners, respectively. Sixty-three percent of phone calls were successful and Patient Partners attended 50% of appointments with their patients. Focus groups demonstrated resounding acceptability of the Patient Partner role.

CONCLUSIONS

Volunteer undergraduate Patient Partners are a beneficial adjunct to DSME delivery in the resource-constrained environment of a student-run free clinic.

Protocol for project IMPACT (improving millions hearts for provider and community transformation): a quasi-experimental evaluation of an integrated electronic health record and community health worker intervention study to improve hypertension management among South Asian patients

BACKGROUND

The Million Hearts® initiative aims to prevent heart disease and stroke in the United States by mobilizing public and private sectors around a core set of objectives, with particular attention on improving blood pressure control. South Asians in particular have disproportionately high rates of hypertension and face numerous cultural, linguistic, and social barriers to accessing healthcare. Interventions utilizing Health information technology (HIT) and community health worker (CHW)-led patient coaching have each been demonstrated to be effective at advancing Million Hearts® goals, yet few studies have investigated the potential impact of integrating these strategies into a clinical-community linkage initiative. Building upon this initiative, we present the protocol and preliminary results of a research study, Project IMPACT, designed to fill this gap in knowledge.

METHODS

Project IMPACT is a stepped wedge quasi-experimental study designed to test the feasibility, adoption, and impact of integrating CHW-led health coaching with electronic health record (EHR)-based interventions to improve hypertension control among South Asian patients in New York City primary care practices. EHR intervention components include the training and implementation of hypertension-specific registry reports, alerts, and order sets. Fidelity to the EHR intervention is assessed by collecting the type, frequency, and utilization of intervention components for each practice. CHW intervention components consist of health coaching sessions on hypertension and related risk factors for uncontrolled hypertensive patients. The outcome, hypertension control (<140 mmHg systolic blood pressure (BP) and <90 mmHg diastolic BP), is collected at the aggregate- and individual-level for all 16 clinical practices enrolled.

DISCUSSION

Project IMPACT builds upon the evidence base of the effectiveness of CHW and Million Hearts® initiatives and proposes a unique integration of provider-based EHR and community-based CHW interventions. The project informs the effectiveness of these interventions in team-based care approaches, thereby, helping to develop relevant sustainability strategies for improving hypertension control among targeted racial/ethnic minority populations at small primary care practices.

TRIAL REGISTRATION

This study protocol has been approved and is made available on Clinicaltrials.gov by NCT03159533 as of May 17, 2017.

A pilot study of a Community Health Agent-led type 2 diabetes self-management program using Motivational Interviewing-based approaches in a public primary care center in São Paulo, Brazil

Background

Rates of noncommunicable diseases (NCDs) such as type 2 diabetes are escalating in low and middle-income countries such as Brazil. Scalable primary care-based interventions are needed to improve self-management and clinical outcomes of adults with diabetes. This pilot study examines the feasibility, acceptability, and outcomes of training community health agents (CHAs) in Motivational Interviewing (MI)-based counseling for patients with poorly controlled diabetes in a primary care center in São Paulo, Brazil.

Methods

Nineteen salaried CHAs participated in 32 h of training in MI and behavioral action planning. With support from booster training sessions, they used these skills in their regular monthly home visits over a 6 month period with 57 diabetes patients with baseline HbA1cs > 7.0%. The primary outcome was patients’ reports of the quality of diabetes care as measured by the Portuguese version of the Patient Assessment of Chronic Illness Care (PACIC) scale. Secondary outcomes included changes in patients’ reported diabetes self-management behaviors and in A1c, blood pressure, cholesterol and triglycerides. We also examined CHAs’ fidelity to and experiences with the intervention.

Results

Patients reported improvements over the 6 month period in quality of diabetes care received (PACIC score improved 33 (+/−19) to 68 (+/−21) (p < .001)). They reported increases in physical activity (p = .001), consumption of fruits and vegetables (p < .001) and medication adherence (p = .002), but no decreases in consumption of high-fat foods (p = .402) or sweets (p = .436). Participants had mean 6-month A1c levels 0.34% points lower than at baseline (p = .08) and improved mean LDL (−16.1 mg/dL, p = .005) and triglyceride levels (−38.725 mg/dL, p = .002). Of the 16 CHAs observed in fidelity assessments, 13 were categorized as medium- or high-performing on MI skills, while 3 were low-performing. CHAs expressed enthusiasm about learning new skills, and many described a shift from advice-giving to encouraging patients to define their own goals.

Conclusion

In resource-scarce settings, it is essential to fully utilize existing primary care resources to stem the epidemic of diabetes and other NCDs. Our pilot results support the potential of training CHAs to incorporate effective diabetes self-management support into their routine patient encounters.

Trial registration

NCT02994095 12/14/2016 Registered retrospectively.

Community Health Workers and the Management of Noncommunicable Diseases Among Rural Health Clinics in Limpopo Province, South Africa: A Pilot Study

South Africa's rise in noncommunicable diseases (NCDs) and health care provider shortages has generated the need for community health workers (CHWs) in rural areas. However, roles and interactions with clinic staff are not well understood. Interviews with health care workers at community clinics in Limpopo Province revealed common themes, including resource scarcity, clinic-patient partnerships, management of NCDs, and collaboration between professionals. The data did not support CHW-physician interactions, necessitating further research to describe these practices and to evaluate CHWs' impact on patient outcomes. The CHW involvement in rural clinics is essential to patient-clinic partnerships and may help close treatment gaps in resource-poor areas.

New Roles for Medical Assistants in Innovative Primary Care Practices

OBJECTIVE

To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs.

DATA SOURCES/STUDY SETTING

Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes.

STUDY DESIGN

Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014.

DATA COLLECTION/EXTRACTION METHODS

Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency.

PRINCIPAL FINDINGS

New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type.

CONCLUSIONS

New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services.

Improving diabetes care and outcomes with community health workers

BACKGROUND

Type II diabetes continues to be a major health problem in USA, particularly in minority populations. The Diabetes Equity Project (DEP), a clinic-based diabetes self-management and education program led by community health workers (CHWs), was designed to reduce observed disparities in diabetes care and outcomes in medically underserved, predominantly Hispanic communities.

OBJECTIVE

The purpose of this study was to evaluate the impact of the DEP on patients' clinical outcomes, diabetes knowledge, self-management skills, and quality of life.

METHODS

The DEP was implemented in five community clinics from 2009 to 2013 and 885 patients completed at least two visits with the CHW. Student's paired t-tests were used to compare baseline clinical indicators with indicators obtained from patients' last recorded visit with the CHW and to assess differences in diabetes knowledge, perceived competence in managing diabetes, and quality of life. A mixed-effects model for repeated measures was used to examine the effect of DEP visits on blood glucose (HbA1c), controlling for patient demographics, clinic and enrolment date.

RESULTS

DEP patients experienced significant (P < 0.0001) improvements in HbA1c control, blood pressure, diabetes knowledge, perceived competence in managing diabetes, and quality of life. Mean HbA1c for all DEP patients decreased from 8.3% to 7.4%.

CONCLUSION

Given the increasing prevalence of diabetes in USA and documented disparities in diabetes care and outcomes for minorities, particularly Hispanic patients, new models of care such as the DEP are needed to expand access to and improve the delivery of diabetes care and help patients achieve improved outcomes.

Type 2 diabetes is associated with vertebral fractures in a sample of clinic- and hospital-based Latinos

Latinos are the fastest growing ethnic population in the United States and type 2 diabetes is a major health burden in this population, but little effort has been made to study the prevalence of diabetic vertebral fragility in Latinos. We performed a cross-sectional study to determine vertebral fracture prevalence in a hospital-based population of South Texas residents (N = 296). We defined fractures in X-rays as a >20% reduction in vertebral body height. Numerous variables were recorded, including age, body mass index, indicators of diabetes management and others. 71% of the sample (N = 296) was Latino. The prevalence of vertebral fracture was increased in diabetic subjects relative to non-diabetic subjects (diabetic 27.9%, non-diabetic 13.8%) and, regardless of sex and diabetics status, decreased in Latinos relative to non-Latinos (Latino 16.7%, non-Latino 26.4%). These data suggest that vertebral fractures may be a growing concern for diabetic Latinos as well as diabetics of any racial/ethnic background.

National Strategies to Decrease the Burden of Diabetes and Its Complications

Comparative results from national strategies for diabetes care and prevention are needed to understand the impact and barriers encountered during the implementation process. Long-term outcomes are limited, but results on intermediate outcomes and processes of diabetes care measures are available from translational research studies. In this narrative review, we highlight programs with nationwide reach, targeting various ethnic, racial, and socioeconomic populations with diabetes. We describe the implementation strategies, the impact on clinical outcomes, specific barriers, and cost-effectiveness results of national efforts aimed at improving diabetes care and prevention in the USA.

Community health workers in primary care practice: redesigning health care delivery systems to extend and improve diabetes care in underserved populations

New, comprehensive, approaches for chronic disease management are needed to ensure that patients, particularly those more likely to experience health disparities, have access to the clinical care, self-management resources, and support necessary for the prevention and control of diabetes. Community health workers (CHWs) have worked in community settings to reduce health care disparities and are currently being deployed in some clinical settings as a means of improving access to and quality of care. Guided by the chronic care model, Baylor Health Care System embedded CHWs within clinical teams in community clinics with the goal of reducing observed disparities in diabetes care and outcomes. This study examines findings from interviews with patients, CHWs, and primary care providers (PCPs) to understand how health care delivery systems can be redesigned to effectively incorporate CHWs and how embedding CHWs in primary care teams can produce informed, activated patients and prepared, proactive practice teams who can work together to achieve improved patient outcomes. Respondents indicated that the PCPs continued to provide clinical exams and manage patient care, but the roles of diabetes education, nutritional counseling, and patient activation were shifted to the CHWs. CHWs also provided patients with social support and connection to community resources. Integration of CHWs into clinical care teams improved patient knowledge and activation levels, the ability of PCPs to identify and proactively address specific patient needs, and patient outcomes.

Alliance system and policy change: necessary ingredients for improvement in diabetes care and reduction of disparities

Reducing diabetes inequities requires system and policy changes based on real-life experiences of vulnerable individuals living with the condition. While introducing innovative interventions for African American, Native American, and Latino low-income people, the five community-based sites of the Alliance to Reduce Disparities in Diabetes recognized that policy changes were essential to sustain their efforts. Data regarding change efforts were collected from site leaders and examined against documents provided routinely to the National Program Office at the University of Michigan. A policy expert refined the original lists to include only confirmed policy changes, scope of change (organizational to national), and stage of accomplishment (1, beginning; 2, adoption; 3, implementation; and 4, full maintenance). Changes were again verified through site visits and telephone interviews. In 3 years, Alliance teams achieved 53 system and policy change accomplishments. Efforts were implemented at the organizational (33), citywide (13), state (5), and national (2) levels, and forces helping and hindering success were identified. Three types of changes were deemed especially significant for diabetes control: data sharing across care-providing organizations, embedding community health workers into the clinical care team, and linking clinic services with community assets and resources in support of self-management.

Expanding and sustaining integrated health care-community efforts to reduce diabetes disparities

To reduce racial and ethnic disparities in diabetes care and outcomes, it is critical to integrate health care and community approaches. However, little work describes how to expand and sustain such partnerships and initiatives. We outline our experience creating and growing an initiative to improve diabetes care and outcomes in the predominantly African American South Side of Chicago. Our project involves patient education and activation, a quality improvement collaborative with six clinics, provider education, and community partnerships. We aligned our project with the needs and goals of community residents and organizations, the mission and strategic plan of our academic medical center, various strengths and resources in Chicago, and the changing health care marketplace. We use the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change conceptual model and the Consolidated Framework for Implementation Research to elucidate how we expanded and sustained our project within a shifting environment. We recommend taking action to integrate health care with community projects, being inclusive, building partnerships, working with the media, and understanding vital historical, political, and economic contexts.

Strengthening the Effectiveness of State-Level Community Health Worker Initiatives Through Ambulatory Care Partnerships

The transformation of the US health care system and the recognition of the effectiveness of community health workers (CHWs) have accelerated national, state, and local efforts to engage CHWs in the support of vulnerable populations. Much can be learned about how to successfully integrate CHWs into health care teams, how to maximize their impact on chronic disease self-management, and how to strengthen their role as emissaries between clinical services and community resources; we share examples of effective strategies. Ambulatory care staff members are key partners in statewide initiatives to build and sustain the CHW workforce and reduce health disparities.

Evaluating the Effect of a Community-Based Lay Health Advisor Training Curriculum to Address Immigrant Children's Caries Disparities

Previous programs had not designed the culturally adequate Lay Health Advisor (LHA) oral health training curriculum for medically underserved population. We evaluated the effects of LHA training curriculum for addressing immigrant children's caries disparities in their access to dental care. We used a pre/post-test study design. Immigrant women were recruited from churches, schools, and immigrant centers in an urban area. Four training classes were held. Each training cycle lasted 15 consecutive weeks, consisting of 1 weekly 2-h training session for 12 weeks followed by a 3-week practicum. The curriculum included training in caries-related knowledge, oral hygiene demonstrations, teaching techniques, communication skills, and hands-on practice sessions. Thirty-seven LHA trainees completed the course and passed the post-training exam. The data were collected using self-report questionnaires. The level of oral health knowledge, self-efficacy and attitudes toward oral hygiene were significantly increased after LHA training. There was a significant and over twofold increase in trainees' oral hygiene behaviors. An increase of >20% in LHA and their children's dental checkup was observed following training. After training, LHAs were more likely to have 3+ times of brushing teeth [Odds Ratio (OR) = 13.14], brushing teeth 3+ minutes (OR = 3.47), modified bass method use (OR = 30.60), dental flossing (OR = 4.56), fluoride toothpaste use (OR = 5.63) and child's dental visit (OR = 3.57). The cross-cultural training curriculum designed for immigrant women serving as LHAs was effective in improvement of oral hygiene behaviors and access to dental care.

Integrating community health workers within Patient Protection and Affordable Care Act implementation

CONTEXT

The Patient Protection and Affordable Care Act's (PPACA) emphasis on community-based initiatives affords a unique opportunity to disseminate and scale up evidence-based community health worker (CHW) models that integrate CHWs within health care delivery teams and programs. Community health workers have unique access and local knowledge that can inform program development and evaluation, improve service delivery and care coordination, and expand health care access. As a member of the PPACA-defined health care workforce, CHWs have the potential to positively impact numerous programs and reduce costs.

OBJECTIVE

This article discusses different strategies for integrating CHW models within PPACA implementation through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology (HIT) efforts, and also discusses payment options for such integration.

RESULTS

Title V of the PPACA outlines a plan to improve access to and delivery of health care services for all individuals, particularly low-income, underserved, uninsured, minority, health disparity, and rural populations. Community health workers' role as trusted community leaders can facilitate accurate data collection, program enrollment, and provision of culturally and linguistically appropriate, patient- and family-centered care. Because CHWs already support disease management and care coordination services, they will be critical to delivering and expanding patient-centered medical homes and Health Home services, especially for communities that suffer disproportionately from multiple chronic diseases. Community health workers' unique expertise in conducting outreach make them well positioned to help enroll people in Medicaid or insurance offered by Health Benefit Exchanges. New payment models provide opportunities to fund and sustain CHWs.

CONCLUSION

Community health workers can support the effective implementation of PPACA if the capacity and potential of CHWs to serve as cultural brokers and bridges among medically underserved communities and health care delivery systems is fully tapped. Patient Protection and Affordable Care Act and current payment structures provide an unprecedented and important vehicle for integrating and sustaining CHWs as part of these new delivery and enrollment models.

Integrated community-healthcare diabetes interventions to reduce disparities

Racial and ethnic minorities suffer disproportionately from diabetes-related morbidity and mortality. With the creation of Accountable Care Organizations (ACOs) under the Affordable Care Act, healthcare organizations may have an increased motivation to implement interventions that collaborate with community resources and organizations. As a result, there will be an increasing need for evidence-based strategies that integrate healthcare and community components to reduce diabetes disparities. This paper summarizes the types of community/health system partnerships that have been implemented over the past several years to improve minority health and reduce disparities among racial/ethnic minorities and describes the components that are most commonly integrated. In addition, we provide our recommendations for creating stronger healthcare and community partnerships through enhanced community support.

Effectiveness of a community health worker-led diabetes self-management education program and implications for CHW involvement in care coordination strategies

PURPOSE

The purpose of this study was to evaluate the effectiveness of a Community Health Worker (CHW)-led diabetes self-management education (DSME) program and to understand how CHWs and primary care providers (PCPs) work together to provide comprehensive diabetes care.

METHODS

A quantitative pre- and postassessment of change in patients' blood glucose levels (A1C), blood pressure, and body mass index was performed to determine the clinical effectiveness of the program. Qualitative, semi-structured interviews with 5 CHWs and 7 PCPs were conducted to assess how CHWs were incorporated into clinical teams and their impact on care delivery and diabetes-related outcomes.

RESULTS

Patients who participated in the program experienced a statistically significant decrease in mean A1C levels and systolic blood pressure readings 1 year post baseline. CHWs provided high-quality care and bridged the gap between patients and care providers through diabetes management support and education, medication assistance, access to community resources, and social support.

CONCLUSIONS

CHWs play a variety of roles in helping patients overcome barriers to diabetes control and can be successfully integrated into a health care system's care coordination strategy.

Community Diabetes Education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker

AIMS

The purpose of this randomized controlled trial was to determine the impact of a culturally tailored diabetes education program led by a community health worker (CHW) on the HbA1c, blood pressure, body mass index (BMI) and lipid status of uninsured Mexican Americans with diabetes.

METHODS

Adult patients were recruited from a community clinic and randomized into intervention (n=90) and control (n=90) groups. Both groups received usual medical care from clinic physicians. The intervention group participated in the Community Diabetes Education (CoDE) program over 12 months. The primary outcome of interest was HbA1c. Secondary outcomes included blood pressure, BMI and lipid status. Variations in outcomes over time were assessed within groups and between groups using linear mixed-models and an intention-to-treat approach. Assessment of changes in HbA1c, blood pressure and lipid status over 12 months included variables to control for modifications made to antidiabetic, antihypertensive and lipid lowering medications.

RESULTS

There was no difference in baseline characteristics between the intervention and control groups. Mean changes of HbA1c over 12 months showed a significant intervention effect (-.7%, p=.02) in the CoDE group compared with controls. HbA1c decreased significantly from baseline to 12 months within the intervention (-1.6%, p<.001) and control (-.9%, p<.001) groups. No differences between groups for secondary outcomes were found.

CONCLUSIONS

This study supports the effectiveness of CHWs as diabetes educators/case managers functioning as integral members of the health care team in community clinic settings serving uninsured Mexican Americans.

The role of community health workers in diabetes: update on current literature

Community health worker (CHW) interventions have been found to be a promising strategy for improving diabetes outcomes, especially among low-income and racial and ethnic minority populations. This review serves as an update of the literature published since 2011 on CHWs' role in diabetes care. In our review of the most current literature, we noted several key areas of advancement. These areas include community-based participatory research approaches to intervention development and evaluation, analyses of the cost effectiveness of CHW interventions, evaluation of sustainability through integrated team-based approaches, thorough descriptions of characteristics and training of CHWs, and delineation of the scope of practice and most effective roles for CHWs.