Despite the documented successes of CHW programs, the CHW model has not been widely adopted within integrated health care systems. A major barrier to adoption of CHW programs has been the lack of sustained funding for CHW services [17,19]. Historically, many CHW programs were supported by grants, as most payers were unwilling to fund these initiatives [4,17,19.] In 2008, the Centers for Medicare and Medicaid Services provided a mechanism to support CHW activities by approving a Medicaid state plan amendment authorizing payment for CHWs who worked under Medicaid-approved providers, such as physicians and nurses [19]. However, the lack of data available regarding the costs, cost-effectiveness, and potential costs savings of CHW programs continues to serve as a barrier to adoption [13,20].
Baylor Scott & White Health North (BSWH), formerly Baylor Health Care System in Dallas, Texas, created the CHW-led Diabetes Equity Project, a 5-year program supported with funding from Merck Foundation’s Alliance to Reduce Disparities in Diabetes, with the goal of reducing observed disparities in diabetes care and outcomes in the medically underserved, predominantly Hispanic communities surrounding BSWH hospitals [16,21,22]. The program featured specially trained, bilingual CHWs who served as members of primary care teams in 5 community clinics and delivered a culturally relevant diabetes self-management and education curriculum (DSME) targeting barriers to diabetes management commonly experienced by Hispanics. The objective of this study was to assess the impact of a CHW-led diabetes educucation program (DEP) on hospital utilization trends and to evaluate the return on investment of the program.
Methods
Setting
BSWH is one of the largest nonprofit health care systems in the United States and includes 46 hospitals, > 800 patient care sites, > 6000 affiliated physicians, 35,000 employees, and an accountable care organization. This study was conducted in 5 community clinics located in the Dallas metroplex surrounding BSWH North hospitals. The community clinics serve low-income, uninsured, and chronically ill patients. The study was approved by the Baylor Research Institute institutional review board.
DEP Intervention
The DEP program consisted of 2 initial 60-minute educational sessions and quarterly clinical assessments scheduled for 30 to 60 minutes for a maximum of 6 patient-contact hours over 12 consecutive months. The DSME curriculum for DEP was adapted from CoDE, a pilot program implemented in a Dallas clinic serving a largely uninsured Mexican American population [23]. Patients who participated in CoDE for 12 months experienced a significant reduction in HbA1c [23,24]. During the 2 educational sessions, the CHWs educated DEP participants about diabetes and the importance of blood glucose control, medication adherence, diet, and exercise. In addition to the educational sessions, CHWs performed quarterly clinical assessments of HbA1c, blood pressure, weight, and foot condition (visual and monofilament assessment). They also assessed self-management behaviors and facilitated goal setting at each visit. The CHWs documented patient visits in the electronic health record and contacted the patient’s primary care provider immediately if the patient was symptomatic or had critical blood glucose or blood pressure measurements as defined by program protocol.
Participants
Study participants were recruited from the clinics or referred by Baylor care coordinators following hospital visits related to uncontrolled diabetes from September 2009 to July 2013. Participants had to be 18 years or older with a diagnosis of type 2 diabetes and be uninsured or underinsured. Although the program targeted Hispanic patients, all patients who met the inclusion criteria were eligible to participate. To control for internal threats to validity such as history and maturation biases, we created a control group consisting of clinic patients who had a diagnosis of diabetes and met the DEP inclusion criteria but who did not enroll in DEP.