Skip to main content

Peer Support and the Patient-Centered Medical Home Project

In 2011, Peers for Progress was awarded and began planning for a comprehensive diabetes management project funded by the Bristol-Myers Squibb Foundation’s Together on Diabetes Initiative. The purpose of the project is to demonstrate and evaluate the ability of a comprehensive approach to diabetes management based in a primary care patient-centered medical home (PCMH) and emphasizing peer support and community outreach activities to improve health outcomes of the target population (approximately 4,000 low-income Latinos with diabetes).  The project will take place over 36 months with a 2 year implementation period.

This project is based on the assumption that the PCMH model, peer support programs and community outreach activities all play major roles in engaging low-income minorities to improve self-management behaviors and achieve improved outcomes for their diabetes.  The design involves a closely evaluated demonstration project to assess the attainment of the following outcomes:

  • Engagement in regular clinical care and self-management
  • Improvement in self-management behaviors such as medication adherence, physical activity, healthy diet, non-smoking, etc.
  • Improvement in clinical indicators such as HbA1c, blood pressure, BMI, etc., and
  • Improvement in general and diabetes-specific quality of life

Additionally, we will select a research sample of 400 patients (from among the 4,000) for further study of intensive, ongoing peer support.

In this project, peer supporters will be part of the extended patient care team. They will work closely with patients and their families to encourage and facilitate access to regular clinical care, deliver diabetes education, assist patients with implementation of diabetes care plans, provide regular and ongoing follow up and support for diabetes management issues, and link patients to needed community resources. Program materials developed by the project team and Alivio staff can be found below and on our Spanish language/Recursos en Español webpage under the tab Proyecto con Alivio.

Model of organizational interactions detailing linkages between clinic and community resources
Model of organizational interactions detailing linkages between clinic and community resources

Sustainability is built into the very structure of the project through including organizations already committed to making PCMH and peer support central parts of their programs.  Implementation of the demonstration project will take place at Alivio Medical Center in Chicago, IL, a federally-qualified health center dedicated to providing quality, cost-effective health care to the Latino community. In addition, Peers for Progress, the National Council of La Raza and TransforMED will prepare a large number of relevant resources for nationwide dissemination through their vast channels of networks. A critical component to these dissemination activities is our National Peer Support Collaborative Learning Network.