Community Health Workers at the Patient’s Home: Evaluation of Care
Clayton Velicer MPH
The ability to work in non-traditional medical settings gives peer supporters, promotoras, community health workers (CHWs) and other community-based caregivers a distinct advantage. Providing home-based visits for chronic disease care, for example, can benefit patients who otherwise may experience barriers to care because of culture, socioeconomic and/or health-related barriers. Previous research in this area has found home visits by CHWs to improve health outcomes for African American and Latino and Mexican American adults with type 2 diabetes.
Nelson and colleagues recently published a protocol paper highlighting the Peer-Support for Achieving Independence Diabetes (Peer-AID) intervention being conducted in King County, Washington, that aims to examine the effectiveness of CHWs in delivering diabetes self-management education in a home-based setting.
This blog highlights the Peer-AID protocol paper, explains its unique study design, and discusses implications for future care.
Background and Participants
The purpose of the Peer-AID study is to evaluate the clinical and cost-effectiveness of home-based CHW care to improve health outcomes among low-income patients with poorly controlled type 2 diabetes. Participants will receive health care at three different health systems. A total of 297 participants, between 30 and 70 years old, low-income and from diverse racial and ethnic backgrounds, have been recruited from a county hospital, a VA hospital and local community health center. As part of the study, they will receive either a home-based intervention over 12 months, or standard care.
The core component of the intervention is disseminating adoption of self-management behaviors that lead to improvements in type 2 diabetes control. Specifically, CHWs will work with their clients at their homes to set behavioral goals, identify feasible actions to achieve those goals, evaluate the progress of the actions toward the goals, and revise actions to make them more effective. Self-efficacy is prioritized, as increased self-efficacy is linked to improved quality of life, patient satisfaction, and glycemic control.
At the first visit, the CHW will help the patient evaluate personal diabetes self-management behaviors, health history, health care access, and health care utilization. The CHW and patient will then collaboratively develop an individualized diabetes self-management plan. Six mandatory education topics include general diabetes information, blood sugar information, blood glucose monitoring, treatment, diet, physical activity and medication. Other topics will be included based on the initial assessment. A complete set of education and training protocols is available online.
Training for CHWs
Training for CHWs is consistent with the American Diabetes Association and American Association of Diabetes Educators self-management education recommendations. The CHWs are trained to work with patients to set behavioral goals and improve self-efficacy based on a client-centered style and motivational interview techniques. Overall, the CHWs will complete 60 hours of training including didactic sessions, in-class exercises and field practices and they will receive training in health coaching and motivational interviewing by a professional health coach.
CHWs will be trained to provide social support for participants (e.g., joining group community-based activities that complemented home visits), and encourage family and other members of participants’ support networks to help participants by encouraging lifestyle changes and medication adherence, attending clinic visits, and providing emotional support.
Cultural and linguistic competency is also emphasized in the intervention, according to participants’ preference. Bi-lingual CHWs communicated in the patients’ primary language while educational materials are provided in both Spanish and English.
The Peer-AID study includes both primary and secondary outcomes, with the primary outcome being the participants’ HbA1c level. Secondary measurements include health-related quality of life, and diabetes self-management based on the Summary of Diabetes Self-Care Activities measurement (e.g., general and specific diet, exercise and physical activity, medication adherence, blood-glucose testing, foot care, and smoking).
The Peer-AID study plans to evaluate costs based on training, CHW utilization, and healthcare costs including self-reported clinic utilization, hospitalization and medication use.
As mentioned, one of the unique skills that peer support workers and CHWs can provide to chronic disease management is the ability to provide care outside the traditional medical center. CHWs and peer support workers may more easily gain access to a participant’s home because of shared cultural and community background, and in some cases, lived experience with the specific medical condition.
Neilson and colleagues highlight some of the mechanisms that may make peer supporters and community health workers particularly effective when providing home-based care:
“Basing the intervention in the home allows observation of home and social conditions affecting diabetes management, provides participants a more relaxed and comfortable setting, eliminates logistical barriers to attending diabetes education in classes or clinics, provides opportunities for CHWs to role-model and observe participants in practicing self-management behaviors and allows CHWs to meet household members and enlist their support in helping the participant self-manage.”
By evaluating a wide variety of health outcomes and behaviors over a 12 month period, the Peer-AID study will provide a unique opportunity to examine long term effectiveness of these home-based visits. Furthermore, by evaluating the costs associated with this program, Neilson and colleagues may be able to demonstrate to healthcare providers the financial benefit of providing home-based visits to those with diabetes. If effective in reducing hospitalizations, this model may be of particular interest to providers working with usage populations as a method of controlling costs. We encourage our readers to share their thoughts and experiences of home-based care from peer supporters, CHWs and promotoras and we look forward to the results of this promising study.