In chronic disease fight, help comes from new care team member

Patients might struggle to understand how to handle a new diagnosis or manage their chronic disease. This can be especially true for patients with prediabetes or hypertension who need support and guidance to make the lifestyle changes needed to improve their health and well-being. To help, a health system in Texas integrated community health workers (CHWs) into the care team.

Baylor Scott & White Health (BSWH)—one of the largest non-profit health systems in Texas—has employed more than 100 community health workers in eight departments and programs. CHWs provide disease-specific health education and facilitate goal setting for uninsured and Medicare populations at Baylor Scott & White Health, an AMA group member.

The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies.

The AMA has also developed online tools and resources to help physicians manage their patients’ hypertension, through Target: BP™, a national initiative co-led by the AMA and American Heart Association.

Community health workers were introduced to BSWH through a five-year grant to deliver a diabetes prevention program. The program is composed of extensive training for CHWs in delivering diabetes education to the community and they were subsequently embedded in four community care clinics.

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As part of their group membership benefits, the AMA worked in collaboration with BSWH leadership to develop an on-site training program customized to meet the unique needs of their CHWs.

“Everyone was incredibly enthusiastic and looking for ways to best support their patients by educating and empowering their CHWs,” said Renee DuBois, MPH, senior practice transformation adviser at the AMA. She led a one-day training event covering topics to help CHWs succeed in their work with patients.

“Our training included techniques on listening with empathy, health coaching, team culture and appreciative inquiry—and provided an opportunity for the CHWs to practice and role-play situations together,” DuBois said.

“When you think about how much time a provider has to see a patient—maybe 15 or 20 minutes at the most—that’s not a lot of time to address all the concerns the patient has,” said Patricia Pugh, RN, a certified diabetes educator and program director for chronic disease management at BSWH in Dallas. “Having the care team able to take over and spend that quality time, we could spend anywhere from an hour to an hour and a half with the patient for that initial visit.

“We can also find out a lot just because the way the community health workers are perceived more as a peer relationship versus a quote-unquote ‘provider,’” she added.

Provide health education

When a Baylor Scott & White Health physician has a patient with prediabetes, hypertension or any other chronic disease, the community health worker receives a referral. During their first meeting, the CHW will provide basic health education, such as healthy eating, being active, taking medications, risk reduction, problem solving and healthy coping.

“I’ve seen them work with someone who was diagnosed with prediabetes and spend an hour and a half going through everything that they eat in a given day,” said Pugh, adding that CHWs show patients “small changes that they can make and working with the patient to empower them to make those small changes so that they don’t develop diabetes and it’s pretty phenomenal.”

Patients are encouraged to meet with the CHWs as often as needed. If patients have a new diagnosis, the community health worker will spend more time with them to ensure they understand what to do. Once patients are stable, they often choose to continue to see the CHW because they like that accountability.

Enhance patient communication

Bilingual CHWs are used to bridge the gap between the hospital and medical home for high-risk, uninsured patients. These professionals help uninsured patients with appointment scheduling, medication access, transportation and completion of medical forms. CHWs connect about 70% of the referred patients they receive to a primary care physician.

“They’re really great in the prevention world, so we make sure they [CHWs] are spending time with patients with prediabetes or prehypertension because that’s an area that we can really make an impact in,” said Pugh. “Having a team of trained community health workers go into the home, we’ve seen great outcomes with having a better understanding of the challenges that patients have at home.

“We’ve run into situations where there’s someone who stays at home all day, every day because the family members may work 12 or 14 hours a day. They’re lonely,” she added. “Having a community health worker understand that and provide resources for that, navigating them to other services are things that the patient doesn’t want to tell the provider because they don’t want to burden them with this information.”

These home visits have shown success in helping patients improve their chronic disease control by addressing their social needs.