How Can Community Health Centers Best Sustain Gains from Diabetes Self- Management Training: Outcomes from the PLEASED Intervention

Transcription

1 How Can Community Health Centers Best Sustain Gains from Diabetes Self- Management Training: Outcomes from the PLEASED Intervention Michele Heisler, MD, MPA VA Center for Clinical Management Research & University of Michigan Medical School

2 THE PROBLEM: A1c Improvements Achieved by Diabetes Self-Management Training Don t Last Immediate 1-3 Months >4 Months Norris, Diabetes Care 2002

3 We ve Developed Effective Six-Month Community Health Worker (CHW)-Led Diabetes Self-Management Programs CHASS is a health center (FQHC) serving low-income, predominantly Latino community in Detroit

4 Key Components of Six-month CHW Program Journey to Health/El Camino a la Salud:11 two-hour, culturally tailored group diabetes self management classes One-on-One Support: behavioral goal setting and follow-up ( action plans ), social support, linkage to resources Clinic visits:accompany clients to at least one provider visit, provide help navigating the health care system (Spencer, AJPH, 2011) (Heisler, AJPM, 2010) (Two Feathers, AJPH,2008)

5 Personal Diabetes Action Plan

6 Mean A1c Values Decreased 0.9% Points after Six-Month Program (Spencer M et al, AJPH 2012)

7 But, THEN WHAT??? No resources for health professional-led follow-up to short-term self-management programs Need flexible, sustainable, low-cost programs that do not rely on health professional staff to help support patients to maintain gains

8 PLEASED Study AIM Compare two different models of follow-up self-management support over 12 months: 1) weekly optional drop-in group sessions with telephone outreach to those unable to attend the face-to-face sessions delivered by trained Peer Mentors ( Manos Amigos ) 2) Monthly pro-active telephone outreach by the Community Health Workers

9 Peer Mentors/ Manos Amigas CHASS patients with diabetes who completed JTH 46 hours of training in group facilitation and MI skills (TS Tang et al, Diab Edu 2011) (TS Tang et al, Pat Ed Couns, 2010)

10 Study Methods Parallel, Three-Arm Randomized Control Trial Enhanced Usual Care Six-Months Journey tohealth+12-months Peer Program Six-Months Journey to Health+12-Months Monthly CHW Primary Study Outcomes (BL, 6M, 12M, 18M) A1c Diabetes-Specific Social Support Diabetes-Specific Distress Changes within and between groups analyzed using intention-to-treat approach with repeated measures

11 Patients Assessed for Eligibility (n= 800) Ineligible (n=406) Refused (n=57) Unable to Reach (n=177) Enrolled & Randomized (n=160) JTH+PEER (n=60) JTH+CHW (n=56) Control (n=44) 18-month pt survey & A1c: (n=35) A1c only: (n=2) Deceased: 2 Lost to Follow-Up: month survey & A1c: (n=34) A1c only: (n=2) Deceased: 1 Lost to Follow-Up: month survey & A1c: (n=30) A1c only: (n=4) Deceased: 1 Lost to Follow-Up: 9

12 Baseline Characteristics (N=160) Measures Control JTH+PEER JTH+CHW (n=44) (n=60) (n=56) Mean Age Female 57% 53% 64% Income<$20k 77% 92% 82% On Insulin 30% 20% 25% Latino/a 79% 82% 91% Mean A1c

13 Changes in Mean A1c over Time from Linear Mixed Model

14 Changes in Diabetes-Specific Social Support Over Time

15 Changes in Diabetes-Specific Distress over Time

16 Other Secondary Outcomes Also at 18 months: improved LDL levels (-13 mg/dl) compared to baseline and to 6 month levels (p<.02) Improved systolic blood pressure (-5.5 mm hg) compared to baseline (p<.03) Decreased waist circumference (-1.3 inches) compared to baseline (p=.003)

17 Limitations Follow-up rate at 18-months of 67% was low (very low-income, highly mobile population) Conducted at only one site, so results may not be generalizable to other sites Did not formally assess cost effectiveness (peer stipends of $1,000 over 12 months, and CHW annual salary of $20k)

18 Conclusions Both low-cost strategies evaluated are equally effective in maintaining short-term gains achieved through a more intensive program For long-term ongoing diabetes selfmanagement efforts in low-resource communities, we may need only to look toward individuals in own communities as valuable sources of self-management support

19 Thank you Tricia Tang, PhD Marti Funnell, RN, MS Gloria Palmisano, BA Brandy Sinco, MS Edie Kieffer, PhD Michael Spencer, PhD, MSW CHASS CHWs Peer Mentors/Manos Amigas Peers for Progress REACH Detroit Steering Committee