Using Community Health Workers to
Reduce Disparities in Diabetes Care
Lee Hargraves, PhD
Warren Ferguson, MD
Celeste Lemay,
Lemay MPH,
MPH RN
Department of Family Medicine and Community Health
UMass Medical School
Joan Pernice,, MS,, BSN
Massachusetts League of Community Health Centers
Joanne Calista, MSW
atya a Gorodetsky,
Go odets y, MEd
d
Tatyana
Central Massachusetts AHEC, Outreach Worker Training Institute
Partners
Partners



Massachusetts League
of Community Health Centers
University of Massachusetts Medical School
Outreach Worker Training Institute
off C
Central
t l Mass
M
AHEC
Support
S ppo t
Robert Wood Johnson Foundation
Finding Answers: Disparities Research for Change
Commonwealth Medicine, University of
Massachusetts Medical School
Backg o nd
Background
Community Health Workers (CHW
(CHW’s)
s) have
gained prominence as members of the
health care workforce
Working in communities of racial and
ethnic
th i minorities,
i iti
serving
i as liaisons
li i
between individuals & the health care
system
In diabetes care the reported
p
effectiveness of CHWs on health behaviors
are mixed
Comm nit Health Workers
Community
Wo ke s





Provide culturally appropriate health
education and information
Assist people getting health services
Provide social support to vulnerable
populations
Advocate for communities and individuals
Often hired specifically for their
understanding of diverse populations
Built Using the
Care Model Framework
Self--Management
Self
The Chronic Care Model provides a model
to support patients living with a chronic
health condition to manage their disease
Requires
q
collaboration between patients
p
&
health care professionals
Interrelationship of self
self--management,
management
patient--physician communication, and
patient
adherence are well documented
Goals of Project
Train CHWs in Diabetes SelfSelf-Management
in the context of the Chronic Care Model
Patients receiving care from trained CHWs
will:
Have success with selfself-management
Have improvements in managing
diabetes and reducing cardiovascular
risk
Intervention



Six pairs of community health centers,
centers
Matched to be similar in size, racial and
ethnic populations served, and
performance in Phase 1 of a statewide
disparities collaborative were
Randomized to an intervention of
enhanced patient support by CHWs
Implementation
Developed 45
45--hour CHW Diabetes SelfSelfmanagement Certificate Course
Curriculum
CHWs received training from March 2007
through May 2007
Supervisors received training in May 2007
Curriculum Development
45-Hour
45H
CHW C
Certificate
tifi t Course
C
Core Competencies + Diabetes
and Self
Self-Management
Management Support
1. Service Coordination Skills
2. Interpersonal Skills
3. Communication & Interviewing
g Skills
4. Organizational Skills
5. Presentation & Facilitation Skills
6. Advocacy and Leadership Skills
7. Cultural Awareness & Sensitivity Skills
8. Diabetes management and support
Implementation (continued)
CHWs working in health care teams within
the health centers from June 1, 2007
through June 30, 2008
Ongoing CHW Training utilizing
conference calls or workshops every 6
weeks
CHW and patient interaction data collected
utilizing an Encounter Form
Data Collection
Quantitative
Encounter Form
P
Population
l ti off F
Focus P
Patient
ti t R
Registry
i t
(i.e., PECS; EMR)
Clinical process/outcomes (e.g.,
(e g HbA1c,
HbA1c LDL)
of ~100 patients/health center
Qualitative
Interviews with CHWs and Supervisors
The Encounter Form
One page long
Includes type/length of contact
Check list of activities
Self--management
Self
g
goal
g
setting
g
Patient’s confidence in SMG
The Encounter Form
Self--Management Behaviors
Self
Ask the patient:
On how many of the last seven days….

Have you followed a healthful eating plan?

Did you do at least 30 minutes of physical activity

Did you test your blood sugar?

Did you check your feet?

Did you take your diabetes medicine?
The Encounter Form
Identified Self
Self--Management Goal:

What?

When?

Where?

How often?
f
Patient Demographics
Patient Characteristics Number of Patients Enrolled Mean Age in years (st err)
Gender Male
Female Ethnicity Latino
Black, non‐Hispanic
White, non‐Hispanic
Others
Missing
Insurance Public
Private
Others
Uninsured
Unknown
Community Health Center
y
by‐Community Health Worker Random Assignment No CHWs CHWs 921 494 52.5 (13.0)
54.9 (14.0)
449 (48.7%) 231 (46.8%) 472 (51.3%) 263 (53.2%) 241 (26.2%) 125 (25.3%) 182 (19.8%) 60 (12.2%) 327 (35.5%) 260 (52.6%) 82 (8.9%)
37 (7.5%)
89 (9.7%) 12 (2.4%) 449 (48.9%) 308 (62.4%) 129 (14.08%)
56 (11.3%)
125 (13.6%) 69 (14.0%) 192(20.9%) 58 (11.7%) 26 (2.8%) 3 (0.6%) Results: Encounter Forms
Between June 2007 and June 2008:



1198 Encounters with 540 patients in
6 community
it health
h lth centers
t
724 Encounters
E
t
with
ith 288 (58%) patients
ti t living
li i
with diabetes in the population of focus
474 Encounters with 252 patients not in the
population
p
p
of focus
Results: Encounter Forms
Most occurred individually,
individually either over the
phone (49%) or face
face--to
to--face (44%)
The majority (83%) of Encounters lasted
30 minutes or less
69% of Encounters included recording or
discussing
d
a selfself
lf-management goall
Example of SM Goal:
Goal: Diet



pt added more leafy greens to his diet..
diet
Continued focus as before.
pt will follow a strict healthful plan
p
p
everyy
day at each mealtime.
Pt works @ McDonalds and he will try to
d
decrease
the
th carbs
b intake.
i t k
Example of SM Goal: Exercise



Pt will walk around his house,
house 7 days a wk
for 15 min.
Exercise at the Gym/Walk at the mall
everyday AM & PM
Exercise/walking while running errands in
the neighborhood once/day
once/day..
Example of SM Goal:
Blood Glucose Monitoring



After a third time on glucometer teaching feels
confident doing FSBS.
Pt has not seen a doctor over a year* Pt will
start FBSB twice a day, fasting
Pt glucometer has been broke for 2 months, has
not ck blood sugar. Pt given Rx
Example of SM Goal:
Checking Feet


1. Check feet at night daily.
g
, drink soyy milk
2. Diet - will eat vegetables,
check feet in a.m and after shower at
home x2/day.
x2/day
Results: Encounter Forms
Five Most Common SMG
N=752
30%
25%
Percent
25%
24%
21%
20%
15%
15%
10%
5%
5%
0%
Keeping/Scheduling
Appt
Monitoring blood
sugar
Modifying diet
Exercising
Adhering to
medication
Results: Encounter Forms
Percent
Five Most Common Educational Strategies
N=1198
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
39%
29%
21%
19%
13%
General diabetes
information
Healthful eating
strategies
Exercise strategies
Glucose testing
strategies
Medication
Adherence
strategies
Results: Encounter Forms
For patients who had more than one
encounter & completed the Diabetes SelfSelfCare Activities at 2 or more visits
(N=171):
Patients reported an increase in the
number of days that they have checked
their feet
Pre: mean of 3.7
3 7 days vv. Post: 4.8
4 8 days,
days p=.001
001
Results: Encounters and Self
Management Goals
CHWs were more likely to have
encounters with patients who had been
seen in the health center once a year in
the previous 3 years
Patients at centers with a CHW were more
likely to have a documented Self
Self-Management Goal than patients receiving
care at control sites
Percentage of Patients with
Documented SMG in Past Year
*
*
*
*
P < 0.05
Community Health Workers
No Community Health Workers
Self-Management Goals at
SelfHealth Centers with CHWs
Percentage change SMG setting before
and after by Race/Ethnicity
Latino
45 to 51%
+ 6%
p < 0.001
Black, nonnon-Hispanic
50 to 76%
+ 26%
p = 0.01
White, nonnon-Hispanic
44 to 62%
+ 18%
p < 0.001
Note: Results from a multivariable model that included age, gender, number of visits, and
clustering of patients within community health centers (GEE model)
Self-Management Goals
Selfat CHCs without CHWs
Percentage change SMG setting before
and after by Race/Ethnicity
Latino
37 to 34%
-3%
n.s
Black, nonnon-Hispanic
20 to 22%
+ 2%
n.s..
n.s
White, nonnon-Hispanic
24 to 19%
- 5%
n.s
Note: Results from a multivariable model that included age, gender, number of visits, and
clustering of patients within community health centers (GEE model)
Percentage of Patients with
Documented LDL in Past Year
Community Health Workers
No Community Health Workers
Percentage of Patients with
Documented HbA1c in Past Year
Community Health Workers
No Community Health Workers
Percentage of Patients with
HbA1c < 8 in Past Year
Before
After
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Community Health Workers
No Community Health Workers
Interviews
Inte ie s and Focus
Foc s G
Groups
o ps
CHWs Focus Groups:
6 weeks after deployment
p y
At conclusion of intervention
S
Supervisors:
i
Interview 6 weeks after deployment
Focus Group at conclusion of
intervention
Conclusions
Concl sions




Ongoing training and contact decreased issues
and problems with burnout as all CHWs
remained with the p
project
j
Utilizing an Encounter Form was an effective tool
for collecting
g data related to CHWs’ work
CHWs can be effective in assisting patients to
set selfself-management goals, a first step in the
path to behavior change
One year is a very short time period to improve
patient outcomes related to diabetes and CVD
Policy
Polic



Sustainability of community health workers is
problematic, particularly in difficult economic
times
CHWs can be a valuable member of the health
care team,, especially
p
y for populations
p p
with
chronic health conditions
Continue to investigate the CHW role in assisting
to build the medical home