Reports From the Field

Evaluation of a Diabetes Care Coordination Program for African-American Women Living in Public Housing

Journal of Clinical Outcomes Management. 2015 August;22(8)

References

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047–53.

2. Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Atlanta: U.S. Department of Health and Human Services; 2014.

3. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden: U.S., 2005-2050. Diabetes Care 2006;29:2114–6.

4. Tang TS, Brown MB, Funnell MM, Anderson RM. Social support, quality of life, and self-care behaviors among African Americans with type 2 diabetes. Diabetes Educ 2008;34:266-76.

5. Crabtree K, Sherrer N, Rushton T, Willig A, Agne A, Shelton T, Cherrington A. Diabetes connect: African American men's preferences for a community-based diabetes management program. Diabetes Educ 2015;41:118-26.

6. Kirk JK, D'Agostino RB Jr, Bell RA, Passmore LV, Bonds DE, Karter AJ, Narayan KM. Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care 2006;29:2130–6.

7. Batts ML, Gary TL, Huss K, Hill MN, Bone L, Brancati FL. Patient priorities and needs for diabetes care among urban African American adults. Diabetes Educ 2001;27:405–12.

8. Horowitz CR, Colson KA, Hebert PL, Lancaster K. Barriers to buying healthy foods for people with diabetes: evidence of environmental disparities. Am J Public Health 2004;94:1549–54.

9. Haas L, Maryniuk M, Beck J, et al; 2012 Standards Revision Task Force. National standards for diabetes self-management education and support. Diabetes Care 2013;36 Suppl 1:S100–8.

10. Cené CW, Haymore LB, Ellis D, Whitaker S, Henderson S, Lin FC, Corbie-Smith G. Implementation of the power to prevent diabetes prevention educational curriculum into rural African American communities: a feasibility study. Diabetes Educ 2013;39:776–85.

11. Feathers JT, Kieffer EC, Palmisano G, et al. The development, implementation, and process evaluation of the REACH Detroit Partnership's Diabetes Lifestyle Intervention. Diabetes Educ 2007;33:509–20.

12. Rahman S, Hu H, McNeely E, et al. Social and environmental risk factors for hypertension in African Americans. Fla Public Health Rev 2008;5:64–72.

13. US Bureau of the Census. Available at www.cityofboston.gov/dnd/PDR/Maps_and_Neighborhood_Profiles.asp.

14. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood) 2010;29:835–43.

15. Fulp RS, McManus KD, Johnson PA. Barriers to purchasing foods for a high-quality, healthy diet in a low-income African American community. Fam Community Health 2009;32:206–17.

16. Fawcett SB, Schultz JA. Supporting participatory evaluation using the Community Tool Box online documentation system. Community-Based Participatory Research for Health. San Francisco: Jossey-Bass; 2008: 419–23.

17. Collie-Akers V, Schultz JA, Carson V, Fawcett SB, Ronan M. REACH 2010: Kansas City, Missouri evaluating mobilization strategies with neighborhood and faith organizations to reduce risk for health disparities. Health Prom Pract 2009;10(Suppl 2):118S–127S.

18. Fawcett SB, Boothroyd R, Schultz JA, Francisco VT, Carson V, Bremby R. Building capacity for participatory evaluation within community initiatives. J Prev Interven Comm 2003;26:21–36.

19. Sepers CE Jr, Fawcett SB, Lipman R, Schultz J, Colie-Akers V, Perez A. Measuring the implementation and effects of a coordinated care model featuring diabetes self-management education within four patient-centered medical homes. Diabetes Educ 2015;41:328–42.

20. Yin RK. Case study research: Design and methods. Sage; 2013.

21. Mead H, Andres E, Regenstein M. Underserved patients' perspectives on patient-centered primary care: does the patient-centered medical home model meet their needs? Med Care Res Rev 2014;71:61–84.

22. Fawcett S, Schultz J, Watson-Thompson J, Fox M, Bremby R. Building multisectoral partnerships for population health and health equity. Prev Chronic Disease 2010;7:A118. Epub 2010 Oct 15.

23. Fixsen DL, Blase KA, Naoom SF, Wallace F. Core implementation components. Res Soc Work Prac 2009; 19:531–540.

24. Cooper JO, Heron TE, Heward WL. Applied behavior analysis. 2nd ed. Pearson; 2007.

25. Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health 2010;31:399–418.

26. Jack L, Jack NH, Hayes SC. Social determinants of health in minority populations: a call for multidisciplinary approaches to eliminate diabetes-related health disparities. Diabetes Spectrum 2012;25:9–13.

In this article, we describe the project and effects on diabetes-related clinical health outcomes.

Methods

Setting

Whittier Street Health Center (WSHC) is a federally qualified community health center that serves over 25,000 patients annually. The WSHC is situated in the heart of Boston’s Roxbury neighborhood, close to 5 public housing developments; 83% of WSHC patients live in public housing units. Roxbury is an underserved neighborhood with high rates of poverty, violence, and disease [12]. African Americans comprise the majority of residents living in Roxbury, making up 55.6% of the total population [13].

Diabetes Care Coordination Program

The DCCP took place from December 2011 to June 2013. The DCCP team provided diabetes self-management education, support, and comprehensive diabetes care using the patient-centered medical home (PCMH) model [14] and Diabetes Health Ambassadors as mediators for program delivery ( Figure 1 ). Team members included: 1) a patient navigator (BA degree and completed an 8-week patient navigator course at the health department), 2) a diabetes nurse case manager, 3) certified diabetes educator, 4) a registered dietitian, 5) a clinical pharmacist, 6) an integrated behavioral health specialist, 7) a primary care physician, 8) an outreach nurse, 9) Diabetes Health Ambassadors, 10) a high-risk nurse case manager, and 11) a program manager. All team members were already working within the medical home except the patient navigator, outreach nurse, and the Diabetes Health Ambassadors. Clinical team members already working at WSHC worked on this project for half of their total hours and sometimes more based on patients’ needs for the duration of this project.

Ambassadors

Diabetes Health Ambassadors, a key component of the program, were hired to engage community members in managing their own health. Five Ambassadors were recruited and retained throughout the project period. Ambassadors were referred by their primary care provider at WSHC and interviewed for the job by the patient navigator. Ambassadors were required to be African-American women with type 2 diabetes living in a public housing unit within the Roxbury neighborhood. In addition, they were required to have their diabetes under control as defined by the WSHC clinical team (HbA1c of 8.0 or below). They also had to want to help other women control their diabetes and be able to deliver motivational presentations as well as have knowledge of available community resources.

Ambassadors received 30 hours of paid training from the certified diabetes educator. During training, they learned the definition, risk factors, and causes of diabetes, how it is controlled, and how to explain this information at a fifth-grade level. Modeling and feedback was used to assure that the information each Ambassador presented was accurate. Ambassadors were also trained on how to measure blood pressure and blood glucose levels and how to respectfully deliver the results. Additionally, Ambassadors received training on cultural competence. Ambassadors were engaged in community outreach and patient support for 20 hours per week and were compensated for their time with stipends.

Participant Recruitment and Outreach

A rolling enrollment for the DCCP began January 2012. The outreach team from the WSHC attended coffee hours at the public housing units and other community events where they conducted onsite blood pressure and glucose screenings as well as educated community members on healthy eating and active lifestyle to reduce the risks for diabetes. Mobile kits were used for testing, so participants received the test results immediately. Two Ambassadors, the outreach nurse, and the patient navigator conducted the outreach events. The set up included two tables, 6 chairs, education materials, and blood pressure and blood sugar screening materials.