Using Community Health
Workers to Reduce Disparities
in Diabetes Care
Lee Hargraves
University of Massachusetts Medical School
Overview of the Project
An evaluation of the effects of enhanced
training of community health workers
(CHWs) to reduce disparities in care in a
low-income, racially and ethnically diverse
population served by community health
centers (CHCs)
Collaborative Partners
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Community Health Centers in MA
Massachusetts League of Community Health
Centers
University of Massachusetts Medical School
Planning Committee that includes,
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Massachusetts Diabetes Prevention and Control
Program
Boston Public Health Commission
MassPRO
The CHW Intervention
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Curriculum enhancement grounded in the
Care Model focused on diabetes
self-management
Reviewed and customized for divergent
cultural, linguistic, and ethnic groups
Multiple training sessions
Deployment of CHWs to Collaborative
Care Teams
Built Using the Care Model
Framework
CHWs connected
to community
More informed and
activated patients
CHWs focused on
self-management
CHW as a team
member
CHW Interventions
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Outreach to patients in each population of focus
Assess self-management, successes and barriers
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Exploration of cultural norms
Advocacy and connecting to community resources
Strengthening of health care relationships
Motivational interviewing to teach self-management
Group meetings
Rely on specific, prescribed interventions using
CHW manual
Community health workers (CHWs)
in health care delivery have
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gained prominence,
proliferated in communities of racial and
ethnic minorities,
increased access to care for underserved
clients, and
assisted individual’s navigation of the
traditional health care system.
Recent review studies have
demonstrated the impact of CHWs
on service delivery
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providing culturally relevant health
education
Assisting with
case management
„ system navigation
„ case finding
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Effects of CHWs on health behaviors
for diabetes care are mixed
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Little is known regarding CHWs impact on
self-management goals and practices.
Additional research is needed to identify:
specific, replicable characteristics of successful
interventions
„ optimal training of CHWs
„ optimal documentation of their activities.
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Organizations that acknowledge the
contributions of CHWs include
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The Institute of Medicine
Centers for Disease Control and Prevention
American Public Health Association
American Association of Diabetes Educators
Each recommends including CHWs as
important members of the health care team.
Recruiting and retaining
CHWs can present challenges
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May lack professional training and
experience
Insufficient training
Unrealistic expectations from co-workers
Burnout
Addressing the challenges
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Recruiting from within the participating
community health centers
Specific training curriculum (45 hour)
incorporating Chronic Disease Model
Training of co-workers regarding CHW role
Training of supervisors
Ongoing support and training
Project’s Unique Aspects
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Baseline data from Diabetes Collaborative
Randomized with match paired
comparison sites
Intensive CHW training with focus on self
management of Diabetes
Training of health care team to assist
integration of CHW
CHW Encounter Forms for data collection
Training Community Health Workers
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Outreach Worker Training Institute’s
45-hour CHW Certification Course
8-Part Training (six hours per week)
8 Outreach core competency sessions
„ 7 Care model and diabetes sessions
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Eight Core Competencies
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Service Coordination Skills
Interpersonal Skills
Communication & Interviewing Skills
Organizational Skills
Presentation & Facilitation Skills
Individual & Community Assessment
Skills
Advocacy and Leadership Skills
Cultural Awareness & Sensitivity Skills
Seven Diabetes Components
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Diabetes in Diverse Communities
Nutrition and Physical Activity for
Diabetes Self Management
Access, Follow-up, and Supportive Care
Cross Cultural Beliefs and Diabetes
Primary, Nursing, and Specialty Care
Individual and Group Teaching Skills
Mental Health and Diabetes Management
Self Management Goal Setting
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Theme woven throughout curriculum
Patient Directed
Stages of Change
Motivational Interviewing
Realistic Goal Setting
Role Playing Exercises
Documentation (The Encounter Form)
Training CHW Supervisors
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Supervisor Certificate Course
6-Hour training for individuals tasked with
overseeing CHWs in the field
„ 2 3-hour weekly sessions
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Supervision strategies, conflict resolution, and
professional boundaries
„ Roles and needs of CHWs and their supervisors
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Evaluation Components
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Quantitative
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Patient Surveys
Clinical Quality Indicators
ACIC Key Personnel Survey
Qualitative
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Focus groups with all CHC teams, post intervention
CHW patient encounter forms
Monthly team narratives
Site visit in-depth interviews at all CHCs
Next Steps
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CHWs become a valued member of the
Health Care Team
Practice skills learned
Acquire new skills
Periodic conference calls
Evaluation includes…
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analysis of sites with trained CHWs
pre/post intervention to control
community health centers without CHW
Patient Surveys
Clinical Outcomes Data
Narrative Reports
Qualitative data via focus groups and
intensive interviews
Clinical Outcome Data
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Health Centers collect and post clinical
outcome data monthly to Virtual Office
Average HgA1c for Population of Focus
„ Percentage of patients with 2 HgA1c tests in
12 month period
„ Self Management Goal setting
„ Cardiac Risk Reduction
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Statins, ACE inhibitors or ARB, ASA, BP, LDL
“Thanks for this great opportunity to learn
more about diabetes in general and also for
the opportunity to share with colleagues
working in the same field.
Healthy People make a Strong Community.”
A graduate of OWTI’s Diabetes CHW Training