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Moderator: Ann Albright, PhD, RD Presentations: La Clinica de La Raza MaineGeneral Health Galveston County Health District
Ann Albright, PhD, RD
La Clinica de La Raza MaineGeneral Health Galveston County Health District
Community Health Worker Community Health Worker Approaches to Implementing Approaches to Implementing
Self Management In Self Management In Community Settings Community Settings
La La Clinica Clinica de La de La Maine General Hospital Maine General Hospital
Galveston County Health District Galveston County Health District
Community Health Worker Community Health Worker Approaches to Implementing Approaches to Implementing
Self Management In Self Management In Community Settings Community Settings
de La de La Raza Raza Maine General Hospital Maine General Hospital
Galveston County Health District Galveston County Health District
Discussants Discussants
Joanne Gallivan Joanne Gallivan Jane Kelly Jane Kelly Donna Rice Donna Rice Aracely Rosales Aracely Rosales
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Discussants Discussants
What’s in a Name? What’s in a Name?
Community Health Workers Community Health Workers Community Health Advocates Community Health Advocates Community Health Representatives Community Health Representatives Peer Health Promoters Peer Health Promoters Lay Health Workers Lay Health Workers Lay Health Educators Lay Health Educators Promotores de Salud Promotores de Salud Others….. Others…..
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What’s in a Name? What’s in a Name?
Community Health Workers Community Health Workers Community Health Advocates Community Health Advocates Community Health Representatives Community Health Representatives Peer Health Promoters Peer Health Promoters
Lay Health Educators Lay Health Educators Promotores de Salud Promotores de Salud
Role Role
Bridges or connectors between health Bridges or connectors between health care consumers and providers to promote care consumers and providers to promote health among groups that have health among groups that have traditionally lacked access to adequate traditionally lacked access to adequate health care health care
Witmer, 1995 Witmer, 1995
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Role Role
Bridges or connectors between health Bridges or connectors between health care consumers and providers to promote care consumers and providers to promote health among groups that have health among groups that have traditionally lacked access to adequate traditionally lacked access to adequate
Core Roles Core Roles
Bridging cultural mediation between Bridging cultural mediation between communities and health care system communities and health care system Providing culturally appropriate and accessible Providing culturally appropriate and accessible health education health education Assuring people get needed services Assuring people get needed services Providing informal counseling & support Providing informal counseling & support Advocating within health systems Advocating within health systems Providing direct services/screening tests Providing direct services/screening tests Building capacity Building capacity
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Core Roles Core Roles
Bridging cultural mediation between Bridging cultural mediation between communities and health care system communities and health care system Providing culturally appropriate and accessible Providing culturally appropriate and accessible
Assuring people get needed services Assuring people get needed services Providing informal counseling & support Providing informal counseling & support Advocating within health systems Advocating within health systems Providing direct services/screening tests Providing direct services/screening tests
Wiggins and Borbon, 1998 Wiggins and Borbon, 1998
Training Training
Various curricula Various curricula What is effective training for teaching self What is effective training for teaching self management in community settings? management in community settings?
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Training Training
What is effective training for teaching self What is effective training for teaching self management in community settings? management in community settings?
Support for Community Health Support for Community Health Workers Workers
Some examples Some examples AADE AADE – – position statement position statement APHA APHA – – position statement position statement CDC CDC – – Established first national database Established first national database Many others… Many others…
Who are we missing?? Who are we missing??
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Support for Community Health Support for Community Health Workers Workers
position statement position statement position statement position statement Established first national database Established first national database
Who are we missing?? Who are we missing??
What can we do to expand What can we do to expand involvement of community involvement of community health workers in self health workers in self management training? management training?
What can we do to expand What can we do to expand involvement of community involvement of community health workers in self health workers in self management training? management training?
Health Promoters use stages of change to improve diabetes in urban Mexican Americans
Health Promoters use stages of change to improve diabetes in urban Mexican-
RWJ Annual Meeting
Tucson, October 18-20
Claire Horton, MD
Joan Thompson, RD La Clínica de la Raza
Oakland, CA
La Clinica de la Raza
w A community health center serving 40,000 patients a year
w 84% Latino, 8% Asian, 6% African American, 2% other
w 85% < federal poverty level
w 7 service sites in Alameda, Contra Costa and Solano Counties (California)
w Medical, health education, mental health, nutrition services, case management, dental, optometry, x-ray, pharmacy and lab services.
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La Clinica de la Raza
A community health center serving 40,000
84% Latino, 8% Asian, 6% African-
85% < federal poverty level
7 service sites in Alameda, Contra Costa and Solano Counties (California)
Medical, health education, mental health, nutrition services, case management,
ray, pharmacy and lab
Key objectives for involving promoters
w La Clinica has a long standing history of community outreach (Escuela de Promotores)
w Desire to integrate the work of Family Medicine and Preventive Medicine with Community Health Education
w Patients in our diabetes program with self management goals had the same A1c average as patients without goals.
Missing ingredient: health promoters to translate medical management into the patient’s reality
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Key objectives for involving promoters
La Clinica has a long standing history of community outreach (Escuela de
Desire to integrate the work of Family Medicine and Preventive Medicine with Community Health Education
Patients in our diabetes program with self management goals had the same A1c average as patients without goals.
Missing ingredient: health promoters to translate medical management into the
Scope of work w Provide culturally appropriate and accessible
health education information and SMS w Teach self management skills w Follow-up on progress of patients and
identification of needs for self management education w Advocate for patient needs w Lead or assist in weekly groups
(depression, walking, diabetes education, support)
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Provide culturally appropriate and accessible health education information and SMS Teach self management skills
up on progress of patients and identification of needs for self management
Advocate for patient needs Lead or assist in weekly groups (depression, walking, diabetes education,
Key interventions w Diabetes education classes w Intensive self management support groups w Depression group w Walking club w One on one counseling using ttm w In-services for providers on ttm w Case conferences included the promoters w Diabetes clinic every two weeks with a promoter w Very recent: Group visits
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Key interventions Diabetes education classes Intensive self management support groups
One on one counseling using ttm services for providers on ttm
Case conferences included the promoters Diabetes clinic every two weeks with a promoter Very recent: Group visits
Addressing Barriers w Language (mono-lingual) and literacy level
– Found ways to engage less literate CHW in other ways – Constant practice and on-going training
w Lack of knowledge in key areas – On-going training (every two weeks) – Constant practice
w Lack of personal transportation – Provided bus passes for public transportation
w Lack of documentation, therefore they cannot be employees – Provide incentives
w Competing priorities in their lives, such as children – Provided child care during promoter meetings
w Health education is often not recognized as a reimbursable service.
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Addressing Barriers lingual) and literacy level
Found ways to engage less literate CHW in other ways going training
going training (every two weeks)
Provided bus passes for public transportation Lack of documentation, therefore they cannot be employees
Competing priorities in their lives, such as children Provided child care during promoter meetings
Health education is often not recognized as a reimbursable service.
Transtheoretical model (TTM) w Counseling methodology
Promoters and providers were trained in ttm and used it to stage patients and customize their intervention using processes of change
w Implementation Patients were staged every 3 months for readiness to change
w Challenges Use of processes of change was difficult to determine, and highly variable depending on promoter and provider
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theoretical model (TTM)
Promoters and providers were trained in ttm and used it to stage patients and customize their intervention using processes of
Patients were staged every 3 months for readiness to change
Use of processes of change was difficult to determine, and highly variable depending on promoter and provider
Key Accomplishments and key lessons
Key accomplishment w *Improved hemoglobin A1c levels for the patients w Created a cadre of highly effective promoters who are eager to
use their skills in other ways to help the Latino community w Integration of promoters with clinical services
Key Lesson w Promoters are passionate, empowered and dedicated people.
They are effective translators of the clinical management of diabetes into the patients’ reality. Once taught, they can transfer these skills to other chronic diseases.
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Key Accomplishments and key lessons
*Improved hemoglobin A1c levels for the patients Created a cadre of highly effective promoters who are eager to use their skills in other ways to help the Latino community Integration of promoters with clinical services
Promoters are passionate, empowered and dedicated people. They are effective translators of the clinical management of diabetes into the patients’ reality. Once taught, they can transfer these skills to other chronic diseases.
Lay Health Educators: A Social Marketing Strategy Addresses the Community Resources and Policy Component of the Chronic Care Model RWJF Diabetes Initiative Annual Meeting October 19, 2006
Natalie Morse, Director Prevention Center, MaineGeneral Health
Lay Health Educators: A Social Marketing Strategy Addresses the Community Resources and Policy Component of the Chronic Care Model RWJF Diabetes Initiative Annual Meeting
Prevention Center, MaineGeneral Health
Communitybased Move More n Build capacity (trails and walking paths, indoor walking spaces)
n Gym memberships (low cost/no cost) n Policy/advocacy (schools, community, worksite) n Nondirective peer support (volunteers) n Linking patients to community resources n Website n Print materials (standardized distribution system) n Chronic disease selfmanagement classes
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based Move More Build capacity (trails and walking paths, indoor walking
Gym memberships (low cost/no cost) Policy/advocacy (schools, community, worksite)
directive peer support (volunteers) Linking patients to community resources
Print materials (standardized distribution system) management classes
Key Objectives n Build network of volunteers who can provide nondirective peer support (Movers and Lay Health Educators)
n Social marketing message
n Refer patients to community resources
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Key Strategies n CDC Best Practices for increasing physical activity* (Creation of or enhanced access to places for physical activity combined with informational outreach activities, and social support interventions in community settings)
n Social Marketing (The Mover is the messenger) *The Guide to Community Preventive Services: What works to promote health?
Community Preventive Services. Oxford University Press, 2005
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CDC Best Practices for increasing physical activity* (Creation of or enhanced access to places for physical activity combined with informational outreach activities, and social support interventions in
Social Marketing (The Mover is the messenger) The Guide to Community Preventive Services: What works to promote health? Task Force on
Community Preventive Services. Oxford University Press, 2005
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
Delivery System Design
Self Management Support
Health System Resources and Policies
Community Organization of Health Care
Wagner’s Chronic Care Model
www.improvingchroniccare.org 22
Productive Interactions
Prepared, Proactive Practice Team
Functional and Clinical Outcomes
Delivery System Design
Decision Support
Clinical Information Systems
Health System Organization of Health Care
Chronic Care Model
www.improvingchroniccare.org
Barriers n Stigma in the community of having diabetes n Explaining to community members and professionals that social marketing is about much more than a mass media campaign.
n Helping health care professionals understand the importance of peer support, and that non professionals are important in referring patients to community resources and delivering the physical activity message.
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Stigma in the community of having diabetes Explaining to community members and professionals that social marketing is about much more than a mass media campaign. Helping health care professionals understand the importance of peer support, and that non professionals are important in referring patients to community resources and delivering the physical activity message.
Lay Health Educator Intervention n Provide nondirective peer
support in community and worksite settings…”gentle encouragement”
n Refer patients to self management resources in the community
n Promote physical activity opportunities
n Lead chronic disease self management classes
n Enroll patients in Move More
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Most important outcome RWJF funding provided time and resources to conduct formative research, develop strategies and establish a network of volunteers. Move More is now a low cost program that can be sustained in a rural setting through the use of volunteers.
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Most important outcome RWJF funding provided time and resources to conduct formative research, develop strategies and establish a network of volunteers. Move More is now a low cost program that can be sustained in a rural setting through the use of volunteers.
Lessons learned n Lay the groundwork (trails, indoor walking places, website, relationships with partners, etc.)
n Slow and steady work with volunteers, health care professionals and community members are key to sustainability.
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Lay the groundwork (trails, indoor walking places, website, relationships with
Slow and steady work with volunteers, health care professionals and community members are key to sustainability.
Ta k e
Ac t i o n Galveston
D. Darlene Cass, RN
Community Health Workers Facilitate Self-
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Community Health Workers -Management
Key objectives for Community Health Coaches
• Provide diabetes self education in non-traditional setting
• Remove barriers to class attendance • Community Health Coaches would be
trained and supported by Galveston County Health District
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Key objectives for using Community Health Coaches
Provide diabetes self-management traditional setting
Remove barriers to class attendance Community Health Coaches would be trained and supported by Galveston County Health District
Key strategies of the intervention
Use Take Action, A Diabetes Self Management Program curriculum Focus - to empower participants to take control of their diabetes through knowledge Participants would use Action Plans to assist in behavior change Coach Support
Coach recruitment Coach training Coach support
Supplies for classes Ongoing support
30
Key strategies of the intervention
Use Take Action, A Diabetes Self- Management Program curriculum
to empower participants to take control of their diabetes through knowledge Participants would use Action Plans to assist
Barriers Easier to find coaches then participants Coach health Pace of working with volunteers Schedules Organizations wanting programs but one of many priorities, low level of support
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Barriers Easier to find coaches then
Pace of working with volunteers
Organizations wanting programs but one of many priorities, low level of
Our Community Health Coach Program Today
nSupport Groups n4 C’s Clinics nTake Action nWhisking Your Way to Health ¨Shelter (Katrina) nAHEC Centers
32
Our Community Health Coach Program Today
53 Coaches in Galveston County
4 Coaches in surrounding counties
19 Coaches in Area Health Education Centers
What Successful Community Health Coaches Look Like
Enthusiastic Dedicated Over come personal barriers Want to share knowledge and experience with others
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What Successful Community Health Coaches Look Like
Enthusiastic
Over come personal
Want to share knowledge and experience with others
Important Outcomes from the Intervention
Training and Teaching Material 100% of coaches reported the materials were clear and tool box was helpful 100% of coaches felt there was adequate information to teach the class 63% were very confident and 31% confident they would be able to teach the Take Action Program after the training
Location of classes in Galveston County 17 locations (churches, social service agencies, senior centers, families, pharmacies) One time series and ongoing classes Support groups
704 participants
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Important Outcomes from the Intervention
Training and Teaching Material 100% of coaches reported the materials were clear and tool box was helpful 100% of coaches felt there was adequate information
63% were very confident and 31% confident they would be able to teach the Take Action Program
Location of classes in Galveston County hurches, social service agencies,
senior centers, families, pharmacies) One time series and ongoing classes
Important Outcomes from the Intervention
97% of participants completing an evaluation indicated they were making changes in the management of their diabetes 88% indicated there was a lot of new information provided 100% indicated Action Plans helped with behavior change 58% never attended diabetes education classes 98% indicated they would use the Diabetic Record
35
Important Outcomes from the Intervention
97% of participants completing an evaluation indicated they were making changes in the management of their diabetes 88% indicated there was a lot of new information provided 100% indicated Action Plans helped with
58% never attended diabetes education
98% indicated they would use the Diabetic
Changing Behavior
Managing Blood Sugar
67 57 55
36 40
0
10
20
30
40
50
60
70
80
Check Blood Sugar
Use Blood Sugar #
Quick Sugar Low Blood Sugar
High Blood Sugar
36
Change in Nutrition
72 6 6
7 4 7 6
4 7
0
10
2 0
3 0
4 0
5 0
6 0
7 0
8 0
Re ad l a be l s
He a l t hy f ood
choi c e s
P l an mea l s Sma l l e r por t i ons
Use S hopp i ng
Li st
Areas of Change
55
74 76
29
48
0
10
20
30
40
50
60
70
80
Carry Quick Sugar
Daily Foot Check
Exercise Depression Cope with Stress
Lessons Learned A Lay Person can successfully teach Take Action, A Diabetes Self Management Program (98% of participants indicated coaches were well prepared
Work at the pace of the volunteers with gentle nudging Continuing support is essential
37
Lessons Learned A Lay Person can successfully teach Take Action, A Diabetes Self- Management Program (98% of participants indicated coaches were well prepared) Work at the pace of the volunteers with gentle nudging Continuing support is essential