Community Health Workers in Action: Mingo County, West Virginia
Clayton Velicer, MPH
In our recent two part blog, we discussed the Institute of Medicine’s recent position paper on Community Health Workers (CHWs) that outlined some of the current challenges facing the CHW workforce and recommendations for steps moving forward. In this blog, we zoom in to the ground level in Mingo County, West Virginia, which has a great CHW program recently featured in AADE In Practice (American Association of Diabetes Educators).
The Mingo County Diabetes Coalition
Mingo County, in rural Appalachia, is categorized by many generations of family living in the same area, resulting in a strong bond with the land as well as the extended family. Diabetes is a major health concern in Mingo County where 13.1% of adults are living with the disease.
To address this problem, the county received supported from the CDC and the Appalachian Regional Commission to organize physical activity and healthy eating programs. The project received additional funding from the Bristol-Myers Squibb Foundation and later partnered with Duke on a research grant from the Center for Medicaid and Medicare Services. The program helped establish a healthcare team that included a physician, certified diabetes educators (CDEs) and community health workers (CHWs).
The CHWs met with patients one-on-one, spending 4 days each week doing home visits and meeting people in the community. Their activities focused on improving medication adherence, diabetes self-management, and healthy eating.
As the first step of their training, CHWs completed a diabetes self-management program. AADE points out that this is a critical component because it provides CHWs with a foundation and practice exercising the skills their clients will need to employ. The CHWs also received leadership training and were asked to provide input on program tools. Finally they received on-the-job training by having CDEs accompany them for the first month of home visits.
How did the Program Work?
The participants in the program saw impressive clinical outcomes. For example, of the patients followed by CHWs that had baseline and 6-month follow up measurement (N=73), 77% lowered their A1C by at least 1%. Even more encouraging was that those with a baseline of A1C of 12% or greater experienced a decrease of 4.4%.
The successes of this program can be illustrated by examples of individual patient improvements and how CHWs working with CDEs provides support in areas of diabetes self-management that may otherwise go unnoticed.
On one home visit, the CHW noticed 169 syringes in Tupperware containers in a patient’s refrigerator. When this was observed, the patient admitted to not taking insulin because she feared taking it, but still picking up the medication at the pharmacy each month. Through coaching, the CHW was able to provide instruction and support on giving injections while the CDE restarted her insulin at a lower dose. As a result of this teamwork and peer support, the patient was able to reduce her A1C.
A second example was an elderly patient with A1C that kept increasing, reaching as high as 13% despite her physician increasing her insulin dose. At a home visit, the patient explained that she was taking the insulin, but explained it was leaking out of her abdomen. When the CHW asked her to demonstrate how she was taking the insulin, it became apparent the plastic sheath covering the pen needle was not properly removed, preventing the insulin from entering her body. The CHW provided guidance on the technique and within 3 months her A1C was within normal range.
The home visits by the CHW also prevented diabetes complications in a number of cases. For example, one morning a CHW noticed a patient’s resting pulse rate was in the 130 range, irregular, and significantly different than the previous week. The CHW contacted a family member and the patient was transported to an emergency room. At the ER, she was diagnosed with acute onset atrial fibrillation. As a result of the early detection, the patient returned home safely one week later.
Take Home Message
Other excellent examples of the unique role that CHW programs can serve in improving diabetes self-management in the community are included in the AADE In Practice article. Even in the brief examples given here, you can see how this program can tackle diabetes self-management challenges that may be missed in more traditional care models. By using CHWs that have experience in the community and have the respect and trust of patients, patients may be more willing to share issues related to their chronic disease care that would not come up with other health care providers. Success stories like these dramatically illustrate the impact of CHWs in diabetes self-management.