ASM 2020 - prize winning presentation NAPCRG 2019
“Nosotros” Approach: Community health workers as trust builders and community healers
RL Ferrer, 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.
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).
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).
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.