Betsy Rodríguez, MSN

Deputy Director

National Diabetes Education Program

2015 Statewide Community Health Worker

Conference

“I’ve learned that people will

forget what you said, people

will forget what you did, but

people will never forget how

you made them feel.”Maya Angelou

Discuss the role of CHWs in the Self-Management of Chronic

Disease

Discuss the distinction between Diabetes Self

Management Education and Diabetes Self-Management

Support.

Describe the role of CHWs in DSME and DSMS.

Identify ways in which CHWs can contribute to Self-

Management of Chronic Disease

Showcase promising practices and required training (KSA)

Discuss key challenges in the integration of CHWs within

the national health system in the Self-Management of

Chronic Disease

Chronic disease is responsible for 7 out of 10

American deaths each year and 75% of U.S. health

care costs.

Hispanics are 50 percent more likely to die from

diabetes or liver disease than whites. Hispanics

are more likely to have uncontrolled high blood

pressure than whites. Hispanics have more

obesity and diabetes than whites.

http://www.cdc.gov/vitalsigns/hispanic-health/

Frontline public health workers who are trusted members

of and/or have an unusually close understanding of the

community served.

This trusting relationship enables CHWs to serve as a

liaison, link, or intermediary between health/social

services and the community to facilitate access to

services and improve the quality and cultural competence

of service delivery.

CHWs also build individual and community capacity by

increasing health knowledge and self-sufficiency through

a range of activities such as outreach, community

education, informal counseling, social support, and

advocacy.

CHW Section, APHA, 2010

CHWs come from the

communities they serve and

bridge the gap between

cultures and the health care

systems.

CHW is an individual

who:

Has expertise or

experience in public

health

Works in an urban or

rural community, in

association with local

health care system

May share ethnicity,

language, socioeconomic

status and life experiences

with residents of the

community

Assists community to

improve health and

increases capacity of

community to meet

health care and

wellness needs of

residents

Provides culturally

appropriate health

education and

information

Assists community

residents in

receiving care

Provide peer

counseling and

guidance provide

direct services and

screenings.

• Bridging cultural mediation between

communities and the health and social

services system

• Providing culturally appropriate health

education and information

• Assuring that people get the services they

need

• Providing informal counseling and social

support

• Advocating for individual and community

needs

• Providing direct services

• Building individual and community capacity

• Role 1: Bridge the gap between communitiesand the health and social service systems

• Role 2: Navigating the health and humanservices system

• Role 3: Advocate for individual and communityneeds

• Role 4: Provide Direct Services

• Role 5: Build Individual and Community Capacity

Project Rationale:

Since 1998, many have relied on the National Community Health Advisor Study as a guide to help identify CHW roles or Scope of Practice (SOP) and core skills and qualities for CHWs.

It is time for a contemporary review of these findings.

Project Aim:

The C3 Project aims to offer CHW and other stakeholder-driven “contemporary” recommendations for consideration and adoption throughout US related to:

CHW Core Roles (together: Scope of Practice)

CHW Core Skills

And affirm existing knowledge about CHW Core Qualities

5/14/2015 UT-C3

REVIEW OF CHW:

Affirmation of identified:

CHW Qualities

5/14/2015 UT-C3

C3 Project Preliminary Findings

A “continuous healing relationship” with a care team and practice system organized to meet their needs for: Effective Treatment (clinical, behavioral,

supportive),

Information and support for their self-management,

Systematic follow-up and assessment tailored to clinical severity and culture

More intensive management for those not meeting targets, and

Coordination of care across settings and professionals

What roles CHWs

can play?

Ongoing process of facilitating the knowledge,

skill, and ability necessary for diabetes self-care.

This process incorporates: needs, goals, and life

experiences of the person with diabetes and is

guided by evidence-based standards.

The overall objectives of DSME are to support

informed decision-making, self-care behaviors,

problem-solving and active collaboration with the

health care team and to improve clinical outcomes,

health status, and quality of life.

Make informed decisions

Cope with the demands of living daily with a

complex chronic disease

Make changes in their behavior that support

their self-management efforts and improve

outcomes.

Link to people living with diabetes to promote sharing knowledge

and experiences

Provide frequent, ongoing, accessible and flexible education and

follow-up.

CHWs interventions can take many forms – phone calls, text

messaging, group meetings, home visits, going for walks together,

and even grocery shopping.

It complements and enhances other health care services by

creating the emotional, social and practical assistance necessary

for managing the disease and staying healthy.

CHWs support functions to complement, supplement

and extend formal primary care services. The role of

CHWs is distinct and does not replace the role of

professional health care providers in diabetes care.

The role of a CHWs is usually a voluntary and or paid

role that is recognized, but generally not well

compensated.

Social support results in psychological and

physical health benefits for both the receiver

and provider.

The support that CHWs offer relies on non-

hierarchical, reciprocal relationships, which

provide a flexible supplement to formal health

system services for people with diabetes.

In addition, DSMS fosters understanding and

trust of health care staff among groups who

otherwise may be alienated from or have poor

access to health care.

Project Dulce, produced by the

Scripps Institute. Uses the

Stanford Chronic Disease

model.

Diabetes Empowerment

Education Program (DEEP)

produced by the University of

Illinois at Chicago. This is a

Racial and Ethnic Approaches

to Community Health (REACH)

US-based program for

Hispanics/Latinos and African

Americans.

Every Diabetic Counts provides

diabetes self-management

education (DSME) training to

Medicare beneficiaries.

The Robert Wood Johnson

Foundation Diabetes Initiative-

Demonstration Projects

Emphasizing Self-management

Figure 3. Type of assistance provided by community health workers to

patients in the diabetes self-management programs.

Davis K L et al. The Diabetes Educator 2007;33:208S-215S

Copyright © by American Association of Diabetes Educators; Published by SAGE Publications

The Robert Wood Johnson Foundation Diabetes Initiative-Demonstration

Projects Emphasizing Self-management

1. Assistance in daily management and living with

diabetes

2. Social and emotional support

3. Linkage to clinical care

4. Ongoing support, extended over time

High blood pressure, impacts almost 1 in 3 adults, and is pre-

ventable, treatable, and manageable.

For individuals with high blood pressure, daily self-care includes

monitoring and management of health behaviors.

Chronic Disease Self-Management Programs help adults with high

blood pressure, diabetes, heart disease, asthma, arthritis, and

other conditions, learn techniques to improve self-management

skills.

CA4Health provides local county partners with tools, training and

guidance to make their communities healthier.

CA4Health’s 4 strategic directions are: reducing consumption of

sugary beverages, increasing availability of smoke-free housing,

creating safe routes to schools, and providing people with chronic

disease with skills and resources to manage their illness.

http://www.phi.org/focus-areas/?program=ca4health

One goal of the initiative is to increase the number of physician-

led teams that link with community-based resources by

engaging community health workers (CHWs)

Strengthen clinical-community linkages by increasing access to

Community Health Workers and Chronic Disease Self-

Management workshops for individuals living with high blood

pressure and/or high cholesterol.

http://www.ca4health.org/wp-content/uploads/2014/05/Imperial_Success_HighlightsFINAL.pdf

Workshops lead by CHWs - Tomando Control de su Salud (Spanish

CDSMP)

Complement and support clinical care

Helping to improve connections between clinics

Contributing to have healthier environments.

To date, more than 300 CHWs have been trained as lay leaders to

offer CDSMP in all 12 CA4Health counties.

Many of the counties have conducted Wellness Summits to create

systems change initiatives to ensure individuals with hypertension

and other chronic conditions obtain recommendations to CDSMP.

Six counties are currently working on workforce development

strategies, four on occupational regulation, and two on financing.

Holyoke Health Center (HHC) has two sites and serves ∼

20,000 patients, most of whom are Spanish speaking.

In 2003, community health workers (CHWs) were added to the

diabetes care team to enhance the capability to engage and

support patients who were not succeeding in managing their

diabetes.

http://clinical.diabetesjournals.org/content/26/2/75.full

The center's CHWs are patients with diabetes who have become

good self-managers of their disease.

The CHWs have had no previous training as medical personnel

The CHWs are members of the Holyoke community and reflect the

demographic population of the community served by HHC.

CHWs are supervised by a nurse who meets with them every week

to review caseload and patient interventions.

3-day training using the Diabetes Education and Empowerment

Curriculum developed by the Midwest Latino Research, Training,

and Policy Center

4-day training in Stanford's Chronic Disease Self-Management

Training Program

3 several sessions of training through the Outreach Worker

Training Institute of Worcester

Several hours of training with the diabetes educator and

nutritionist at HHC.

Patients that do not have pending appointments or who a clinician

believes to be at risk are targeted by CHWs for phone outreach and,

as needed, home visiting to assist them in reestablishing primary

medical care.

CHWs help patients negotiate problems with transportation, child

care, and insurance coverage which are frequent barriers to care.

Outreaching those with poor glycemic control with a more intensive

intervention.

CHWs function as a link between patients and their primary nurse,

medical provider, pharmacist, and other team members to help

resolve such problems.

The proportion of active patients with diabetes (i.e., those who

had been seen within the previous 3 years but who had not had an

appointment within the previous year) improved considerably.

Important improvements in glycemic control.

The average A1C for all patients with diabetes at HHC was

8.4%, and the proportion of patients with A1C levels > 10%

was 18.2%.

3 years later, the average A1C decreased to 7.5%, and the

proportion with A1C levels > 10% declined to 10.8%

CHWs function principally as peer health

educators and may recruit community

members for screening tests or other

services.

In contrast, this project has demonstrated

the utility of integrating CHWs into the

primary care team, both to support ongoing

medical care and to assist patients in

overcoming barriers to adherence to their

medical plan

Patient Protection and Affordable Care Act (ACA)

recognizes CHWs as integral members of the

health care workforce and for the key role that

they can play in achieving the goals of health

care reform through participation in community-

based health teams and patient-centered

medical homes.

MPHI is using CHWs to work with clients with 2 or more chronic diseases to improve self- management by addressing their immediate needs associated with the clients’ social determinants of health.

CHWs deliver “pathways” of services that provide referrals ranging from food, housing and transportation needs to mental health, medication adherence and tobacco cessation counseling.

Innovative Payment Model for CHWs: MPHI is piloting and further developing a payment model for CHWs that is based on both the number of services delivered AND the value of those services based on resolving the client’s needs as well as improving the client’s health outcomes.

Joslin Diabetes Center has been using Community Health Advocates to deliver point of service testing of A1c and BP as well as the delivery of a 3 session diabetes education curriculum they call “On the Road.”

Joslin has been able to show results in A1c and BP control and reduction from the baseline levels to levels determined at the 3 month follow up. This has been shown across rural, suburban and urban settings.

Community Health Advocates have been able to deliver A1c testing and BP measurement in neighborhood settings and have been trained to educate participants (with diabetes or at risk for diabetes) about key monitoring tests as well as information regarding healthy food choices and active living.

Sustainable funding: Single most

mentioned

Grants are often short-term and limited in

focus

Pay and employment

There is a lot of frustration for not being able

to pay CHWs or give them full-time, long-term

work

CHWs services tend to not be reimbursable

Needs around training/certification vary

widely: by state; by agency; by CHW

educational background.

Where certification programs are not

prevalent, there is a strain for employers to

take on the role of training their CHWs

Little awareness/knowledge about the role of

CHWs among other medical professionals

Lack of understanding of CHW role may cause

health care providers to miss opportunities for

integration or to use CHWs as interpreters

The broad array of titles used by CHWs indicates

a potential lack of awareness and use of the

Department of Labor’s CHW standard

occupational classification code

The roles of CHWs as described by titles tend to

be defined by categorical funding sources, which

limits their roles and potential

Health care providers lack awareness of the

unique value that CHWs provide compared with

other health professions (e.g., MAs, RNs) who

often serve overlapping functions with CHWs

Lack of technical and analytic capacity and

access to external data impedes the ability of

health centers to document the contributions of

CHWs

Lack of awareness and knowledge exists across

the provider community about innovations

conducted by CHWs

It is needed delivery models that address

financial and professional concerns for

expanding CHWs engagement.

Diabetes programs include community health

workers as team members in a variety of roles.

There are some preliminary data demonstrating

improvements in participant knowledge and

behavior.

Much additional research, however, is needed

to understand the incremental benefit of CHWs

in multicomponent interventions

Identify appropriate settings and optimal roles

for community health workers in the care of

persons with diabetes.

Conduct a statewide CHW campaign

Implement a statewide infrastructure for

CHW education, training, and

certification

Promote sustainable financing

mechanisms

TAKING INNOVATION TO SCALE: Community Health Workers, Promotores, and the Triple Aim

CHWs/ Promotores augment the role of

diabetes educators and other diabetes care

team members

Promote trust to promote access to DSMTS

Provide DSMTS

Help diabetes educators provide culturally

sensitive care/education

CHWs are ‘natural researchers’ can translate

the reality of exclusion, propose remedies,

and contribute to best practices in forming

public policy with the information they

share”.

Community Health Improvement Navigator

A framework and tool to support hospitals,

health systems, public health, and other

community organizations and stakeholders that

are interested in improving the health of their

communities

It has a search engine/database of proven

community-based interventions that can help

move partnerships from planning to

implementation and action, and in the end, to

improved community health and well-being

http://wwwn.cdc.gov/chidatabase

http://mhpsalud.org/wp-content/uploads/2012/10/Promotores-and-PCMH-E-Book_Final.pdf

• Overview of

Promotores(as) de Salud

and Patient-Centered

Medical Homes

• Roles and Benefits of

Promotores(as) in a

Patient-Centered Medical

Home

• Key Considerations in

Establishing

Promotores(as) as Part of

a Patient-Centered

Medical Home

State Community Health Worker Models

This map highlights state activity to integrate

CHWs into evolving health care systems in key

areas such as financing, education and training,

certification, and state definitions, roles and

scope of practice. The map includes enacted state

CHW legislation and provides links to state CHW

associations and other leading organizations

working on CHW issues in states.

Mapping the Medical Home Movement

This map includes a diverse range of programs

using patient-centered medical homes (PCMH)

and enhanced primary care teams as the model

for improving health care delivery

Peer Support: What is it and does it work?

From Nesta and National Voices, this literature

review analyzed over 1000 research studies on

peer support from around the world to find out

who is involved in it, the type of support

provided and why

http://www.cdc.gov/dhdsp/docs/chw_brief.

pdf

Community Health Worker (CHW) Toolkit

CDC has compiled evidence-based research that

supports the effectiveness of CHWs in the

Community Health Worker Toolkit. The toolkit

also includes information that state health

departments can use to train and further build

capacity for CHWs in their communities, as well

as helpful resources that CHWs can use within

their communities.

http://www.cdc.gov/dhdsp/pubs/chw-toolkit.htm

NDEP’s The Road to Health Toolkit (Kit El

camino hacia la buena salud)

These resources were developed for community

health workers and educators working with

African American or Hispanic/Latino populations

at risk for type 2 diabetes.

http://www.cdc.gov/diabetes/ndep/road-to-

health.htm

NDEP’s Fotonovela “Do it for them! But for

you too. (¡Hazlo por ellos! Pero por ti

también.)”

A bilingual (Spn/Eng) fotonovela featuring

dramatic stories of Latinas talking to Latinas

about preventing or delaying type 2 diabetes and

being healthy for their children and themselves.

http://wwwn.cdc.gov/pubs/CDCInfoOnDemand.aspx?p

ubid=220173

“Whenever there is a need to reflect about

our reality, and the concrete situation in

which we are living, there is a conscious

commitment of a person ready to intervene

and change it”. (Paulo Freire)

Selective memory to remember the good,

logical prudence to not ruin the present, and

challenges to face the future optimistically.

Betsy Rodriguez bjr6@cdc.gov

National Diabetes Education Program

Call 1-800-CDC-INFO (800-232-4636)

TTY 1-(888)-232-6348 or visit www.cdc.gov/info

To order resources, visit www.cdc.gov/diabetes/ndep