Community health workers help patients self-manage diabetes, HbA1c in new study

Community health workers helped patients in a safety-net primary care practice self-manage type 2 diabetes and lower their HbA1C, according to a new study published in Annals of Family Medicine.

Robert L. Ferrer, MD, MPH, of UT Health San Antonio, and colleagues wrote that other studies have demonstrated that community health workers (CHW) — defined by the American Public Health Association as a “frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served” — can be helpful in chronic disease management.

CHW programs can be hard to maintain because of time-limited funding, despite their promise, the researchers wrote. However, a program’s ability to demonstrate cost savings could help “promote sustainability,” they added.

“We would argue that investment in CHWs should not be strictly contingent on demonstrating savings. Community health workers help advance patients’ health and promote health equity, making them essential, fully integrated members of the primary care team,” the researchers wrote. “Community health workers leverage personal and professional experience to navigate social complexity, raising both practitioners’ and patients’ normative expectations for primary care practice.”

For the study, Ferrer and colleagues sought to understand if a practice-integrated CHW intervention could help patients effectively self-manage type 2 diabetes.

The researchers conducted the cohort study in a safety-net primary care practice. The analysis included 986 patients with uncontrolled type 2 diabetes and psychosocial risk factors. CHWs then engaged the patients in “trust building and sensemaking” to better gauge goals and social context, connect them to community resources and navigate health care.

There were three stages of self-care: outreach, in which they met face-to-face; stabilization, in which they collaborated to address the patients’ circumstances; and self-care generativity, in which they worked to achieve self-care competencies.

The multiyear intervention revealed fewer ED and hospital visits and sustained HbA1C reductions, findings that “suggest a path to financial sustainability,” the researchers wrote.

However, they also noted that “it is important to acknowledge the limits of applying individual-level interventions to health conditions whose origins lie in social injustices” and that “community-level change is necessary to address root causes.”

Of all participants:

• 27% did not move past the outreach stage;
• 41% “progressed to stabilization,” where the patient and CHW addressed
• obstacles to self-care; and
• 33% “achieved self-care generativity,” in which the patient committed to self-care.

The 33% who were able to achieve self-care generativity saw greater HbA1c declines — sustained, clinically meaningful reductions for up to 4 years, according to the researchers.

At entry, mean HbA1C was between 10.1% and 10.5%. All groups then experienced significant drops in HbA1C, but there were no significant differences between the groups.

The researchers saw differences in the groups’ outcomes at the fifth HbA1C measurement, which occurred after 859 days. At the 10th measurement, which happened after 1,365 days, the benefits increased. The self-care generativity group had an average of 8.5%, while the outreach group had an average of 8.8% and the stabilization group had a rate of 9% (P = .003).

“The time necessary to achieve clinically meaningful results is not surprising among patients facing multiple challenges, including unmet social needs,” they wrote. “Time was needed for the practice to understand how to help specific patients and for patients to sustain new habits in old settings.”

The study, the researchers concluded, “adds to a growing body of literature on the value of CHWs in chronic disease management.”

References:

• American Public Health Association. https://www.apha.org/apha-communities/member-sections/community-health-workers. Accessed Oct. 6, 2022.
• Ferrer RL, et al. Ann Fam Med. 2022;doi:10.1370/afm.2848.