Abstract
Diabetes disproportionately affects racial and ethnic minorities, rural, and impoverished populations. This case study describes the program components and key lessons learned from implementing Vivir Mejor! (Live Better!), a diabetes prevention and management program tailored for the rural, Mexican American population. The program used workforce innovations and multisector partnerships to engage and activate a rural, mostly Hispanic population. Community health worker (CHW) roles were designed to reach and support distinct populations. Promotoras focused exclusively on health education and patient navigators individually coached patients with chronic disease management issues for the high-risk patient population. To extend diabetes health education to the broader community in Santa Cruz County, promotoras trained lay leaders to become peer educators. Multisector partnerships allowed the program to offer health and social services around diabetes care. The partners also supported provider engagement through continuing education workshops and digital story screening to encourage referrals to the program. Multisector partnerships, including partnering with critical access hospitals, for diabetes management and prevention, as well as using different types of CHWs to implement programs that target high- and low-risk populations are innovative and valuable components of the Vivir Mejor! model.
Keywords
Introduction
Diabetes has serious and costly health consequences. In the United States, 8.3% of the population has diabetes (Geiss et al., 2014), a condition commonly associated with hypertension, obesity, cardiovascular disease, and kidney disease (American Diabetes Association, 2014; Geiss et al., 2014). Racial and ethnic minorities, rural, and impoverished populations are disproportionately affected by diabetes. For example, Hispanics are almost twice as likely as non-Hispanic Whites to be diagnosed with diabetes (Blackwell, Lucas, & Clarke, 2012). Moreover, in recent years, diabetes incidence and prevalence have plateaued among non-Hispanic White adults but this trend was not observed among Hispanics (Geiss et al., 2014).
Among American residents of Mexican origin, diabetes prevalence (18.3%) is higher than for American residents of other Hispanic origins (Schneiderman et al., 2014). Additionally, Mexican Americans residing in rural or unincorporated areas show higher rates of diabetes and associated comorbidities when compared to non-Hispanic Whites or Mexican Americans living in other U.S. regions (Anders et al., 2008; Balcazar et al., 2010; Koopman, Mainous, & Geesey, 2006). One study reported the diabetes prevalence among Hispanic residents in U.S.–Mexico border communities was over 20% (Chang et al., 2013).
Background
The Vivir Mejor! (Live Better!) initiative was implemented between May 2012 and April 2015. The goal of the initiative was to develop a multisector Consortium to enhance the treatment and prevention of diabetes in a high-risk Hispanic population residing in Santa Cruz County, Arizona, which is situated on the U.S.–Mexico border. Its population is 85% Hispanic, and according to 2013 data, 4.9% of total deaths are from diabetes complications compared with 3.5% statewide and 2.9% nationwide (Arizona Department of Health Services, n.d.; Xu, Murphy, Kochanek, & Bastian, 2016). Mariposa Community Health Center (MCHC), a federally qualified health center (FQHC), is the primary health care provider within this rural community and the lead for this initiative.
The Vivir Mejor! initiative was designed based on elements of the chronic care model (CCM; Wagner, 1998). CCM is an approach that is built around the idea that community resources and policies, in combination with coordinated health system functions (e.g., delivery system design, decision support, clinical information systems), enable productive interactions between informed, activated patients and prepared, proactive practice teams. Productive interactions lead to better outcomes by improving clinicians’ treatment decisions, and patients’ understanding of their health and adherence to recommended treatment regimens or behavioral modifications for better health. The initiative aimed to engage and activate a rural, mostly Hispanic population by facilitating productive interactions through multisector partnerships, community health worker (CHW)–led education and outreach, and provider engagement.
CHWs have effectively led diabetes education and outreach programs and supported self-management interventions to improve glycemic control and diabetes knowledge among Mexican Americans (Lujan, Ostwald, & Ortiz, 2007; McCloskey, 2009; Rothschild et al., 2014). Guided by the CCM, Collinsworth, Vulimiri, Snead, and Walton (2014) demonstrated CHWs can effectively embed in primary care teams to provide diabetes education, nutrition counseling, and connection to community resources. The care team produced knowledgeable, activated patients, and proactive interactions between the care team and patient to identify and address needs and improve patient outcomes. However, there is limited literature on interventions designed to meet the needs of Mexican Americans living in rural areas (Brown, Garcia, Kouzekanani, & Hanis, 2002; Ingram, Gallegos, & Elenes, 2005).
The multisector Consortium that support the initiative consists of MCHC, a FQHC, and partners representing a range of health and social service organizations that gave patients access to nutrition counseling, financial literacy classes, exercise classes, among others. Literature on the benefits of and lessons learned from partnerships between FQHCs and community or nonmedical organizations is scant. Benefits and lessons learn around multisector partnerships for diabetes interventions are also not well-documented. To date, research studies have described the benefits of FQHC partnerships with medical organizations, such as academic health centers (American Public Health Association, n.d.; Brutger, 2010) and a federally funded cancer research network (Friedman et al., 2011).
This case study contributes to a gap in the peer-reviewed literature by describing the program components and key lessons learned from the Vivir Mejor! initiative. Organizations working with similar communities can use these strategies to design and implement effective diabetes prevention and management programs for their populations.
Strategies
In this section, we describe key aspects of the initiative that facilitated its success. These include the development and maintenance of the Consortium, workforce innovations in the clearly defined roles for CHWs and lay leaders, and services available to meet diverse client needs. We discuss the challenges and lessons learned that were used to develop strategies to improve the initiative. We conclude this section with a brief discussion of the evaluation results and sustainability beyond the grant period.
Partnership Development
Formation of the Consortium
The Vivir Mejor! Consortium is composed of organizations from various sectors and includes the following types of partners: FQHC, hospital, health education center, community development corporation, and food bank. Although MCHC worked with these partners in the past, they had not been part of a structured Consortium. Grant funding provided the opportunity for MCHC to formalize partnerships with organizations that shared the same goal of improving the health of Santa Cruz County residents. A formal Consortium facilitated more focused effort and commitment to create a system of diabetes prevention and care, as opposed to informal, ad hoc collaborations.
Partners were selected based on their ability to provide services to patients with diabetes that MCHC as the lead partner could not. For example, MCHC did not have any professional staff who could provide nutrition counseling. Carondelet Health Network, the local hospital, employed bilingual certified diabetes educators who were very experienced working in this border community and could provide this service to MCHC patients. Consortium partners and their contributions are listed in Table 1.
Current Consortium Members
Partnership Structure
Each Consortium partner received grant funds in the form of a subcontract for its efforts to fulfill the initiative’s scope of work. For each Consortium partner, the agreement stated the scope of work, amount of grant funds provided, and expectations from participation. The funding level for each partner was projected in the grant application and was proportional to the number of hours provided to project participants per year, plus time for Consortium participation and reporting.
Communication and Organizational Structure
MCHC led the Consortium and brought partners together on a regular basis to foster ongoing participation. Since its inception in 2012, the Consortium met bimonthly for 2 hours to discuss program design and progress, and partner updates, as well as share results. To bring Consortium partners who can occasionally have differing views and priorities, a designated MCHC staff member was responsible for creating the agenda, facilitating the meetings, and ensuring the Consortium agreed on the actionable steps. In addition, MCHC provided structure and direction for the Consortium and was essential to ensure action items were completed.
Workforce Innovation
MCHC has over two decades of experience employing CHWs as part of its services. The Vivir Mejor! initiative provided an opportunity to experiment with designing distinct roles within its workforce, as well as developing lay leaders—an extension of CHWs. The roles are described in more detail below.
Community Health Workers
CHWs are defined by the American Public Health Association as 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 . . . between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
The term CHW serves as an umbrella term for Promotoras de Salud in Latino communities, as well as other titles such as a community health advisors, lay health workers, and patient navigators, among others (Arizona Department of Health Services, n.d.).
MCHC has employed CHWs to conduct outreach, provide group education and individual guidance, and connect individuals to needed services. The CHWs have high school diplomas or equivalent education, experience in community work or leadership roles in the community, and are fluently bilingual in Spanish and English. Although they have similar experience and training, MCHC assigns specific CHW roles along a continuum ranging from focusing on the community for primary prevention to focusing clinically for secondary prevention or treatment. The initiative created two distinct CHW positions to target the high-risk population—Promotoras taught diabetes education classes in group settings, and patient navigators individually coached patients around implementing lifestyle changes to lower HbA1c (glycosylated hemoglobin) levels. The CHWs who contributed to this initiative were supported by a combination of grant funds and clinic revenue. Clinic administration invested in CHW staffing because CHWs enhanced quality of care and improved health outcomes; MCHC currently supports three CHW positions without grant funds.
Lay Leaders
To extend diabetes health education to the broader community in Santa Cruz County with limited financial resources, Promotoras trained lay leaders to become peer educators. Lay leaders are a low-cost alternative to the Promotora-led classes because lay leaders are volunteers who are compensated for transportation costs. Lay leaders—participants of previous diabetes education classes—attended a week-long training that taught them to teach diabetes prevention to community members. After the training, lay leaders taught a pilot class under supervision of a Promotora.
Lay leader-led diabetes classes reached over 800 community members and were especially useful in engaging the low-risk populations in the community. A majority of the participants did not have diabetes and about half were not MCHC patients; many would not have otherwise attended classes because of lack of transportation, child care, or interest in a structured class setting. Furthermore, the lay leader-led classes reached a younger, healthier population and their families who were in a similar age bracket and health status as the lay leaders. As a result, lay leader community classes functioned as an important diabetes prevention tool that reached people outside of the MCHC patient population.
In response to the lay leaders’ broader impact and limited available resources for lay leader training, staff at the University of Arizona Prevention Research Center conducted structured interviews with the Promotoras who trained and supervised the lay leaders to document their experience and lessons learned. Using the interview materials, the Prevention Research Center developed a guide for selecting, training, and supporting lay leaders. The guide describes the most important characteristics of effective lay leaders, the importance of clearly communicating their role and responsibilities, a detailed, actionable guide for training lay leaders, and a framework for sustaining them in their work. The lay leader guide is available at http://azprc.arizona.edu/sites/default/files/lay-leader-manual.pdf.
Vivir Mejor! Services
In rural areas, providers rely heavily on each other to meet the diverse needs of clients, therefore the grant program created an ideal opportunity for MCHC to create partnerships to provide complementary diabetes self-management and prevention services such as nutrition counseling and diabetic-friendly food boxes. Below, we describe the Vivir Mejor! services and the Consortium partner that was responsible for each service area.
The Vivir Mejor! Consortium partners implemented a variety of clinic and community-based services, including diabetes education classes, exercise classes, health care provider engagement and training, nutrition counseling, diabetes self-management, and diabetic-appropriate foods. The services described below, illustrated in Figure 1, were modeled on a number of evidence-based and promising practices (Collinsworth et al., 2014; Mauldon, Melkus, & Cagganello, 2006; McCloskey, 2009; McCloskey, Tollestrup, & Sanders, 2011).
Overview of the Vivir Mejor! Initiative
Diabetes Education Classes
To increase awareness and understanding of the disease, two MCHC Promotoras and three Promotora-trained lay leaders delivered an adapted a version of the Pasos Adelante (Steps Forward) diabetes education curriculum to community members. Pasos Adelante is an evidence-based Spanish-language chronic disease prevention curriculum designed to be implemented by CHWs. MCHC Promotoras modified Pasos Adelante to address diabetes prevention and control. Participants were recruited through provider referrals, MCHC health promotion programs, and word of mouth. MCHC Promotoras delivered classes at the Mexican Consulate, while lay leaders facilitated classes in their homes or at various sites within the community; both classes were free and open to the public. Over the course of the intervention, program staff found that many participants had difficulty attending all eight classes over an extended period of time. Since the data showed that most participants could attend at least five classes, program staff condensed the diabetes education series from eight to five classes. They also eliminated open entry and exit of classes, promoting group cohesion by having the same individuals begin and end the course together.
Diabetes Self-Management Education
Patient navigators at MCHC track participants’ diabetes-related clinical outcomes via electronic health records and provide follow-up self-management education for high-risk patients via home visits. They conduct home assessments to identify social-environmental factors that may be barriers to diabetes self-management, such as access to healthy food, and will connect patients to resources accordingly. In addition, patient navigators work with patients to comply with the meal plan developed during nutrition counseling.
Nutrition Counseling
Carondelet Health Network offered nutrition counseling to MCHC patients with HbA1c levels equal to or greater than eight who were referred by their providers. A nurse practitioner/certified diabetes educator with over 15 years of community experience conducted nutrition counseling sessions. 1 Baseline measures for the initial nutrition appointment included weight, blood pressure, HbA1c level, and current medications. At the appointment, the client and nutrition counselor develop a meal-plan and a MCHC patient navigator schedules a 15-minute follow-up appointment for 3 months later to check-in with the patients and see if their HbA1c level reduced to <8 %. If a client’s HbA1c remained ≥8% at the follow-up appointment, a patient navigator would schedule a third appointment for 3 months later. Participation in follow-up appointments was low.
Other Healthy Lifestyle Services
Using a holistic approach to diabetes self-management, MCHC, Nogales Community Development Corporation, and Nogales Community Food Bank, respectively, offered free exercise classes (e.g., yoga, rhumba, and aerobics), financial literacy classes, and diabetic-friendly food boxes for participants who attended five or more diabetes education classes. The exercise classes were well-attended, and all participants who received vouchers for the food box redeemed them. There was little interest in the financial literacy classes. Program staff found the participants were more interested in assistance with tax preparation and less interested in learning financial management skills. In the next iteration, program staff would like to tailor these classes more to the needs of diabetic patients (e.g., managing budget for a diabetic-friendly diet).
Health Care Provider Engagement and Training
Provider engagement was crucial to the initiative’s success because the Promotoras and patient navigators rely on their referrals to identify suitable patients to recruit. However, the Consortium had to think creatively on capturing the providers’ attention in the context of competing priorities and very busy schedules. The Consortium successfully engaged providers at MCHC in two ways: continuing medical education workshops and digital story viewing.
The Southeast Arizona Area Health Education Center (SEAHEC) planned, implemented, and evaluated a number of health care trainings for health care providers (physicians, nurse practitioners, and physician assistants) and medical assistants. SEAHEC administered the needs assessment both in-person and electronically to ask for priority training topics and preferred continuing education formats. Providers could take these classes as part of their continuing medical education. The goal of the trainings was to increase provider knowledge of culturally sensitive diabetes care. These topics, listed in Table 2, were selected based on the needs assessment and a focus group with nine providers conducted prior to organizing the workshops. On average, 14 providers attended each class, which was the majority of adult primary care providers at that time.
Health Care Provider Trainings
The Consortium made a concerted effort to share the initiative’s vision with clinical providers at MCHC. After attending a multiday digital storytelling workshop, SEAHEC and MCHC staff produced a digital story that highlighted the need for a multisector approach and the success stories that resulted. Digital stories are videos that use many types of media, including photographs, video, animation, sound, music, and a narrative voice. This creative format was more effective than written materials or formal presentations in capturing the providers’ attention because it highlighted the initiative’s impact on key indicators, such as HbA1c reduction, in an engaging way. The digital story (available at http://ruralhealthlink.org/News/TabId/82/ArtMID/664/ArticleID/88/Vivir-Mejor-Digital-Story.aspx) premiered in January 2013, to increase provider appreciation for patient support provided outside of the exam room.
Evaluation Results
The Vivir Mejor! evaluation assessed three aspects of the program: diabetes education classes, nutrition counseling, and diabetes management. The data and methodology are published elsewhere (Kunz et al., 2016) and the effects of Vivir Mejor! on health behaviors and outcomes are described below.
The lay leader-facilitated education sessions reached over 800 community members and Promotora-led classes reached 77 MCHC patients. Of these, 59 community members and all 77 MCHC patients completed pre- and post-surveys. Both groups indicated improved healthy eating habits (e.g., increased fruit and vegetable consumption and decreased consumption of pan dulce [sweet breads]). Participants who attended Promotora-led classes showed statistically significant improvement in reducing their average weekly servings of sugary drinks and increasing average weekly servings of vegetables. These participants also reported taking more walks per week after the diabetes education classes.
Of the 137 participants who attended at least one nutrition counseling session, about 30% had a valid pre- and post-HbA1c measure and showed an average decrease from 10.2% to 8.6% (p < .001). Additionally, to assess the impact of diabetes management services, 243 participants were evaluated using HbA1c measures in their electronic health records. HbA1c was measured 0 to 3 months prior to the intervention and 0 to 3 months before Year 3 follow-up. The pre–post analysis found significant reduction of 0.7% in HbA1c levels (p < .01) among high-risk patients (≥8% HbA1c at baseline).
Sustainability
Given the success of Vivir Mejor!, the Consortium has continued to provide nutrition and physical activity classes focused more generally on chronic disease management and continues to offer nutrition counseling and the tailored food boxes for diabetics who complete diabetes education classes. Moreover, the lay leaders that were trained during the initiative continue to volunteer their time and serve as mentors for others.
Discussion
With support from grant funding, MCHC created and led the Vivir Mejor! Consortium, composed of local organizations from both health and nonhealth sectors. The Consortium offered a continuum of diabetes self-management and prevention services to MCHC patients and the broader Santa Cruz County community, including diabetes education classes, nutrition counseling, diabetic-friendly food boxes, free exercise classes, and free financial literacy classes. The Consortium also engaged MCHC providers through workshops, where they gained new skills (e.g., motivational interviewing), and digital storytelling, where they learned about program and patient successes.
Through the 3-year grant, the Consortium learned that strong leadership and open communication were foundational to its success. Given this strong foundation, the Consortium continues to provide self-management and prevention services for other chronic conditions such as cardiovascular disease. MCHC also expanded its partnership with Carondelet Health Network to provide care coordination activities, particularly for those transitioning from the emergency department to primary care. Additionally, the lay leader training guide is an important resource that will be used to develop adept lay leaders for outreaching to low-risk populations. Given the current shift in the health care landscape toward targeting resources to high-risk patients as a means to curb health care costs, provider organizations must not lose sight of low-risk populations, who may also develop chronic conditions and eventually require costly care.
A limitation to this case study is the lack of data collected to document the effectiveness of the Consortium. Whereas the program evaluation team collected pre- and postdata from diabetes education participants (Kunz et al., 2016), the team did not collect information to quantify the Consortium’s impact on diabetes prevention and management or the community at-large. There is limited guidance in the literature on what measures would capture the benefits of community-level partnerships to effect change. Future research should aim to identify meaningful measures of multisector partnerships (particularly those partnerships that include FQHCs or other safety-net providers, such as critical access hospitals). Understanding how to operationalize multisector partnerships is necessary to better evaluate how these partnerships impact diabetes management and prevention, and the broader community.
Conclusion
The Vivir Mejor! (Live Better!) initiative successfully engaged and activated a rural, mostly Hispanic population in diabetes management and prevention efforts. Multisector partnerships, CHW-led education and outreach, and provider engagement were key components of the initiative that helped bridge barriers to effectively engage this difficult to reach population. Following the Vivir Mejor! model, FQHCs should consider multisector partnerships—including partnering with critical access hospitals—for diabetes management and prevention, and using different types of CHWs to implement programs that target high- and low-risk populations. The program could also be adapted to address different chronic conditions in other rural, Hispanic populations.
Footnotes
Acknowledgements
The authors would like to acknowledge the contributions of community health workers Alicia Sander and Silvia Ochoa to the success of the Vivir Mejor! initiative. The authors also thank Patty Molina, who provided input on this article, and Sean McKenzie, who prepared the Vivir Mejor! evaluation reports that provided important findings to support the development of this case study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Federal Office of Rural Health Policy.
All services pertaining to this project were supported by federal funds. This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health & Human Services (HHS) under grant number DO4RH23596 (“Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care”) and grant number U56RH05539 (Rural Assistance Center for Federal Office of Rural Health Policy Cooperative Agreement). The grant was $450,000 over 3 years. This information or content and conclusions are those of the author and should not be construed as the official position or policy of nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.