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Betsy Rodríguez, MSN
Deputy Director
National Diabetes Education Program
2015 Statewide Community Health Worker
Conference
“I’ve learned that people will
forget what you said, people
will forget what you did, but
people will never forget how
you made them feel.”Maya Angelou
Discuss the role of CHWs in the Self-Management of Chronic
Disease
Discuss the distinction between Diabetes Self
Management Education and Diabetes Self-Management
Support.
Describe the role of CHWs in DSME and DSMS.
Identify ways in which CHWs can contribute to Self-
Management of Chronic Disease
Showcase promising practices and required training (KSA)
Discuss key challenges in the integration of CHWs within
the national health system in the Self-Management of
Chronic Disease
Chronic disease is responsible for 7 out of 10
American deaths each year and 75% of U.S. health
care costs.
Hispanics are 50 percent more likely to die from
diabetes or liver disease than whites. Hispanics
are more likely to have uncontrolled high blood
pressure than whites. Hispanics have more
obesity and diabetes than whites.
http://www.cdc.gov/vitalsigns/hispanic-health/
Frontline public health workers who are trusted members
of and/or have an unusually close understanding of the
community served.
This trusting relationship enables CHWs to serve as a
liaison, link, or intermediary between health/social
services and the community to facilitate access to
services and improve the quality and cultural competence
of service delivery.
CHWs also build individual and community capacity by
increasing health knowledge and self-sufficiency through
a range of activities such as outreach, community
education, informal counseling, social support, and
advocacy.
CHW Section, APHA, 2010
CHWs come from the
communities they serve and
bridge the gap between
cultures and the health care
systems.
CHW is an individual
who:
Has expertise or
experience in public
health
Works in an urban or
rural community, in
association with local
health care system
May share ethnicity,
language, socioeconomic
status and life experiences
with residents of the
community
Assists community to
improve health and
increases capacity of
community to meet
health care and
wellness needs of
residents
Provides culturally
appropriate health
education and
information
Assists community
residents in
receiving care
Provide peer
counseling and
guidance provide
direct services and
screenings.
• Bridging cultural mediation between
communities and the health and social
services system
• Providing culturally appropriate health
education and information
• Assuring that people get the services they
need
• Providing informal counseling and social
support
• Advocating for individual and community
needs
• Providing direct services
• Building individual and community capacity
• Role 1: Bridge the gap between communitiesand the health and social service systems
• Role 2: Navigating the health and humanservices system
• Role 3: Advocate for individual and communityneeds
• Role 4: Provide Direct Services
• Role 5: Build Individual and Community Capacity
Project Rationale:
Since 1998, many have relied on the National Community Health Advisor Study as a guide to help identify CHW roles or Scope of Practice (SOP) and core skills and qualities for CHWs.
It is time for a contemporary review of these findings.
Project Aim:
The C3 Project aims to offer CHW and other stakeholder-driven “contemporary” recommendations for consideration and adoption throughout US related to:
CHW Core Roles (together: Scope of Practice)
CHW Core Skills
And affirm existing knowledge about CHW Core Qualities
5/14/2015 UT-C3
REVIEW OF CHW:
Affirmation of identified:
CHW Qualities
5/14/2015 UT-C3
C3 Project Preliminary Findings
A “continuous healing relationship” with a care team and practice system organized to meet their needs for: Effective Treatment (clinical, behavioral,
supportive),
Information and support for their self-management,
Systematic follow-up and assessment tailored to clinical severity and culture
More intensive management for those not meeting targets, and
Coordination of care across settings and professionals
What roles CHWs
can play?
Ongoing process of facilitating the knowledge,
skill, and ability necessary for diabetes self-care.
This process incorporates: needs, goals, and life
experiences of the person with diabetes and is
guided by evidence-based standards.
The overall objectives of DSME are to support
informed decision-making, self-care behaviors,
problem-solving and active collaboration with the
health care team and to improve clinical outcomes,
health status, and quality of life.
Make informed decisions
Cope with the demands of living daily with a
complex chronic disease
Make changes in their behavior that support
their self-management efforts and improve
outcomes.
Link to people living with diabetes to promote sharing knowledge
and experiences
Provide frequent, ongoing, accessible and flexible education and
follow-up.
CHWs interventions can take many forms – phone calls, text
messaging, group meetings, home visits, going for walks together,
and even grocery shopping.
It complements and enhances other health care services by
creating the emotional, social and practical assistance necessary
for managing the disease and staying healthy.
CHWs support functions to complement, supplement
and extend formal primary care services. The role of
CHWs is distinct and does not replace the role of
professional health care providers in diabetes care.
The role of a CHWs is usually a voluntary and or paid
role that is recognized, but generally not well
compensated.
Social support results in psychological and
physical health benefits for both the receiver
and provider.
The support that CHWs offer relies on non-
hierarchical, reciprocal relationships, which
provide a flexible supplement to formal health
system services for people with diabetes.
In addition, DSMS fosters understanding and
trust of health care staff among groups who
otherwise may be alienated from or have poor
access to health care.
Project Dulce, produced by the
Scripps Institute. Uses the
Stanford Chronic Disease
model.
Diabetes Empowerment
Education Program (DEEP)
produced by the University of
Illinois at Chicago. This is a
Racial and Ethnic Approaches
to Community Health (REACH)
US-based program for
Hispanics/Latinos and African
Americans.
Every Diabetic Counts provides
diabetes self-management
education (DSME) training to
Medicare beneficiaries.
The Robert Wood Johnson
Foundation Diabetes Initiative-
Demonstration Projects
Emphasizing Self-management
Figure 3. Type of assistance provided by community health workers to
patients in the diabetes self-management programs.
Davis K L et al. The Diabetes Educator 2007;33:208S-215S
Copyright © by American Association of Diabetes Educators; Published by SAGE Publications
The Robert Wood Johnson Foundation Diabetes Initiative-Demonstration
Projects Emphasizing Self-management
1. Assistance in daily management and living with
diabetes
2. Social and emotional support
3. Linkage to clinical care
4. Ongoing support, extended over time
High blood pressure, impacts almost 1 in 3 adults, and is pre-
ventable, treatable, and manageable.
For individuals with high blood pressure, daily self-care includes
monitoring and management of health behaviors.
Chronic Disease Self-Management Programs help adults with high
blood pressure, diabetes, heart disease, asthma, arthritis, and
other conditions, learn techniques to improve self-management
skills.
CA4Health provides local county partners with tools, training and
guidance to make their communities healthier.
CA4Health’s 4 strategic directions are: reducing consumption of
sugary beverages, increasing availability of smoke-free housing,
creating safe routes to schools, and providing people with chronic
disease with skills and resources to manage their illness.
http://www.phi.org/focus-areas/?program=ca4health
One goal of the initiative is to increase the number of physician-
led teams that link with community-based resources by
engaging community health workers (CHWs)
Strengthen clinical-community linkages by increasing access to
Community Health Workers and Chronic Disease Self-
Management workshops for individuals living with high blood
pressure and/or high cholesterol.
http://www.ca4health.org/wp-content/uploads/2014/05/Imperial_Success_HighlightsFINAL.pdf
Workshops lead by CHWs - Tomando Control de su Salud (Spanish
CDSMP)
Complement and support clinical care
Helping to improve connections between clinics
Contributing to have healthier environments.
To date, more than 300 CHWs have been trained as lay leaders to
offer CDSMP in all 12 CA4Health counties.
Many of the counties have conducted Wellness Summits to create
systems change initiatives to ensure individuals with hypertension
and other chronic conditions obtain recommendations to CDSMP.
Six counties are currently working on workforce development
strategies, four on occupational regulation, and two on financing.
Holyoke Health Center (HHC) has two sites and serves ∼
20,000 patients, most of whom are Spanish speaking.
In 2003, community health workers (CHWs) were added to the
diabetes care team to enhance the capability to engage and
support patients who were not succeeding in managing their
diabetes.
http://clinical.diabetesjournals.org/content/26/2/75.full
The center's CHWs are patients with diabetes who have become
good self-managers of their disease.
The CHWs have had no previous training as medical personnel
The CHWs are members of the Holyoke community and reflect the
demographic population of the community served by HHC.
CHWs are supervised by a nurse who meets with them every week
to review caseload and patient interventions.
3-day training using the Diabetes Education and Empowerment
Curriculum developed by the Midwest Latino Research, Training,
and Policy Center
4-day training in Stanford's Chronic Disease Self-Management
Training Program
3 several sessions of training through the Outreach Worker
Training Institute of Worcester
Several hours of training with the diabetes educator and
nutritionist at HHC.
Patients that do not have pending appointments or who a clinician
believes to be at risk are targeted by CHWs for phone outreach and,
as needed, home visiting to assist them in reestablishing primary
medical care.
CHWs help patients negotiate problems with transportation, child
care, and insurance coverage which are frequent barriers to care.
Outreaching those with poor glycemic control with a more intensive
intervention.
CHWs function as a link between patients and their primary nurse,
medical provider, pharmacist, and other team members to help
resolve such problems.
The proportion of active patients with diabetes (i.e., those who
had been seen within the previous 3 years but who had not had an
appointment within the previous year) improved considerably.
Important improvements in glycemic control.
The average A1C for all patients with diabetes at HHC was
8.4%, and the proportion of patients with A1C levels > 10%
was 18.2%.
3 years later, the average A1C decreased to 7.5%, and the
proportion with A1C levels > 10% declined to 10.8%
CHWs function principally as peer health
educators and may recruit community
members for screening tests or other
services.
In contrast, this project has demonstrated
the utility of integrating CHWs into the
primary care team, both to support ongoing
medical care and to assist patients in
overcoming barriers to adherence to their
medical plan
Patient Protection and Affordable Care Act (ACA)
recognizes CHWs as integral members of the
health care workforce and for the key role that
they can play in achieving the goals of health
care reform through participation in community-
based health teams and patient-centered
medical homes.
MPHI is using CHWs to work with clients with 2 or more chronic diseases to improve self- management by addressing their immediate needs associated with the clients’ social determinants of health.
CHWs deliver “pathways” of services that provide referrals ranging from food, housing and transportation needs to mental health, medication adherence and tobacco cessation counseling.
Innovative Payment Model for CHWs: MPHI is piloting and further developing a payment model for CHWs that is based on both the number of services delivered AND the value of those services based on resolving the client’s needs as well as improving the client’s health outcomes.
Joslin Diabetes Center has been using Community Health Advocates to deliver point of service testing of A1c and BP as well as the delivery of a 3 session diabetes education curriculum they call “On the Road.”
Joslin has been able to show results in A1c and BP control and reduction from the baseline levels to levels determined at the 3 month follow up. This has been shown across rural, suburban and urban settings.
Community Health Advocates have been able to deliver A1c testing and BP measurement in neighborhood settings and have been trained to educate participants (with diabetes or at risk for diabetes) about key monitoring tests as well as information regarding healthy food choices and active living.
Sustainable funding: Single most
mentioned
Grants are often short-term and limited in
focus
Pay and employment
There is a lot of frustration for not being able
to pay CHWs or give them full-time, long-term
work
CHWs services tend to not be reimbursable
Needs around training/certification vary
widely: by state; by agency; by CHW
educational background.
Where certification programs are not
prevalent, there is a strain for employers to
take on the role of training their CHWs
Little awareness/knowledge about the role of
CHWs among other medical professionals
Lack of understanding of CHW role may cause
health care providers to miss opportunities for
integration or to use CHWs as interpreters
The broad array of titles used by CHWs indicates
a potential lack of awareness and use of the
Department of Labor’s CHW standard
occupational classification code
The roles of CHWs as described by titles tend to
be defined by categorical funding sources, which
limits their roles and potential
Health care providers lack awareness of the
unique value that CHWs provide compared with
other health professions (e.g., MAs, RNs) who
often serve overlapping functions with CHWs
Lack of technical and analytic capacity and
access to external data impedes the ability of
health centers to document the contributions of
CHWs
Lack of awareness and knowledge exists across
the provider community about innovations
conducted by CHWs
It is needed delivery models that address
financial and professional concerns for
expanding CHWs engagement.
Diabetes programs include community health
workers as team members in a variety of roles.
There are some preliminary data demonstrating
improvements in participant knowledge and
behavior.
Much additional research, however, is needed
to understand the incremental benefit of CHWs
in multicomponent interventions
Identify appropriate settings and optimal roles
for community health workers in the care of
persons with diabetes.
Conduct a statewide CHW campaign
Implement a statewide infrastructure for
CHW education, training, and
certification
Promote sustainable financing
mechanisms
TAKING INNOVATION TO SCALE: Community Health Workers, Promotores, and the Triple Aim
CHWs/ Promotores augment the role of
diabetes educators and other diabetes care
team members
Promote trust to promote access to DSMTS
Provide DSMTS
Help diabetes educators provide culturally
sensitive care/education
CHWs are ‘natural researchers’ can translate
the reality of exclusion, propose remedies,
and contribute to best practices in forming
public policy with the information they
share”.
Community Health Improvement Navigator
A framework and tool to support hospitals,
health systems, public health, and other
community organizations and stakeholders that
are interested in improving the health of their
communities
It has a search engine/database of proven
community-based interventions that can help
move partnerships from planning to
implementation and action, and in the end, to
improved community health and well-being
http://wwwn.cdc.gov/chidatabase
http://mhpsalud.org/wp-content/uploads/2012/10/Promotores-and-PCMH-E-Book_Final.pdf
• Overview of
Promotores(as) de Salud
and Patient-Centered
Medical Homes
• Roles and Benefits of
Promotores(as) in a
Patient-Centered Medical
Home
• Key Considerations in
Establishing
Promotores(as) as Part of
a Patient-Centered
Medical Home
State Community Health Worker Models
This map highlights state activity to integrate
CHWs into evolving health care systems in key
areas such as financing, education and training,
certification, and state definitions, roles and
scope of practice. The map includes enacted state
CHW legislation and provides links to state CHW
associations and other leading organizations
working on CHW issues in states.
Mapping the Medical Home Movement
This map includes a diverse range of programs
using patient-centered medical homes (PCMH)
and enhanced primary care teams as the model
for improving health care delivery
Peer Support: What is it and does it work?
From Nesta and National Voices, this literature
review analyzed over 1000 research studies on
peer support from around the world to find out
who is involved in it, the type of support
provided and why
http://www.cdc.gov/dhdsp/docs/chw_brief.
Community Health Worker (CHW) Toolkit
CDC has compiled evidence-based research that
supports the effectiveness of CHWs in the
Community Health Worker Toolkit. The toolkit
also includes information that state health
departments can use to train and further build
capacity for CHWs in their communities, as well
as helpful resources that CHWs can use within
their communities.
http://www.cdc.gov/dhdsp/pubs/chw-toolkit.htm
NDEP’s The Road to Health Toolkit (Kit El
camino hacia la buena salud)
These resources were developed for community
health workers and educators working with
African American or Hispanic/Latino populations
at risk for type 2 diabetes.
http://www.cdc.gov/diabetes/ndep/road-to-
health.htm
NDEP’s Fotonovela “Do it for them! But for
you too. (¡Hazlo por ellos! Pero por ti
también.)”
A bilingual (Spn/Eng) fotonovela featuring
dramatic stories of Latinas talking to Latinas
about preventing or delaying type 2 diabetes and
being healthy for their children and themselves.
http://wwwn.cdc.gov/pubs/CDCInfoOnDemand.aspx?p
ubid=220173
“Whenever there is a need to reflect about
our reality, and the concrete situation in
which we are living, there is a conscious
commitment of a person ready to intervene
and change it”. (Paulo Freire)
Selective memory to remember the good,
logical prudence to not ruin the present, and
challenges to face the future optimistically.
Betsy Rodriguez [email protected]
National Diabetes Education Program
Call 1-800-CDC-INFO (800-232-4636)
TTY 1-(888)-232-6348 or visit www.cdc.gov/info
To order resources, visit www.cdc.gov/diabetes/ndep