ASM 2020 - prize winning presentation NAPCRG 2019

“Nosotros” Approach:  Community health workers as trust builders and community healers

Authors:

RL FerrerL, CG Schlenker, RS Poursani, I Cruz, P Noel, R Palmer, CR Jaén

Department of Family and Community Medicine, UT Health San Antonio, Texas, USA

Context: Promoting patients’ commitment to engage in self-care is a core goal of primary care, yet often elusive in the context of social deprivation.

Objective: To report on an innovative, practice-integrated, community health worker (CHW) intervention designed to promote trusting relationships and effective self-care in patients with type 2 diabetes.

Study Design: Retrospective cohort study.

Setting: Family medicine practice in a safety-net county health care system in San Antonio, Texas, USA.

Population studied: Predominantly Hispanic, low-income primary care patients with uncontrolled type 2 diabetes, and significant psychosocial risk factors.

Intervention: Clinicians identified eligible patients through a diabetes registry and at point of care. Patients were assigned CHWs, who engaged them in trust-building and relationship-based sensemaking to understand their social context, collaboratively identify goals, navigate the health care system, and connect them to community resources.

Outcome Measures:

Primary outcome was patient progress through three prospectively defined stages of self-care: a) Outreach (patient responds to CHW’s invitation to meet face-to-face); b) Stabilization (patient and CHW build trust and create an alliance to address pressing problems within the patient's life circumstances); and c) Self-Care Generativity (patient commits to self-care. Secondary outcome was repeated measures analysis of glycosylated hemoglobin (A1c).

Results: 

From a population of 8,647 patients with diabetes, 986 were referred to the Nosotros Approach over 4 years. Of those, 267 (27.1%) remained in Outreach; 399 (40.5%) progressed to Stabilization; while 320 (32.5%) achieved Self-Care Generativity. Repeated measures ANOVA demonstrates an overall decline in A1c, without group differences, through the 4th A1c measurement occasion (mean follow-up 704 days). Beginning at the 5th A1c measurement occasion (mean 860 days), the self-care generativity group achieved greater declines in A1c (p<.05). The relative advantage of the self-care generatively group grew through the 10th measurement occasion (mean followup 1367 days) when it attained an average A1c of 8.26% vs 9.29% in the engagement group and 9.17% in the stabilization group (p<.003).

Conclusions: 

Community health workers can sustainably engage vulnerable patients, helping them identify and advance long-term self-management goals in the context of formidable social disadvantage.