Abstract
Despite evidence that chronic care management improves outcomes, a framework designed for low income, uninsured populations is still needed to improve health disparities and guide further replication. We describe the Innovative Care for Chronic Conditions framework implemented by a coalition of clinics and agencies to address chronic care management for Mexican Americans with Type 2 diabetes mellitus who have low income and primarily uninsured. The core elements of the framework are described by clinic, home and community settings with community health workers playing an essential role in the delivery of community-based services that address the social determinants of health. Promising results are described. This framework expands the understanding of chronic care management approaches and contributes to further replication of the framework in diverse settings.
Keywords
Background
Type 2 diabetes mellitus (T2DM) management through health behavior modification and blood sugar monitoring and control is important to delay and prevent complications. Approximately 30 million (12.2%) Americans aged 18 years and older were estimated to have T2DM (Centers for Disease Control and Prevention, 2017). People with T2DM have more outpatient visits, use more medications, have higher probability of hospitalizations, and are more likely to require emergency and long-term care, presenting a significant burden on society both in quantity and quality of life and in costs (Huang et al., 2016). Researchers found that individuals with T2DM with good glycemic control (HbA1c ≤ 7) had direct diabetes-related medical costs that were 20% lower than those with poor glycemic control (HbA1c > 9%; Oglesby et al., 2006).
T2DM disproportionately affects Mexican Americans (Centers for Disease Control and Prevention, 2017), and their lack of health insurance affects the ability to access care (Velasco-Mondragon et al., 2016). While the Affordable Care Act was intended to increase health care coverage, service usage, and quality of care for chronic and other conditions, Texas was one of 14 states that did not expand Medicaid and, instead, chose a temporary 1115 Federal Waiver to provide $25 billion in funding covering some of its nearly 5 million uninsured constituents (Mazurenko et al., 2018). The 1115 Waiver provided the opportunity to implement innovative approaches to Chronic Care Management (CCM) for T2DM.
CCM approaches have been in a state of transformation since an original model was proposed two decades ago. The original CCM model called for a restructuring of medical care to ensure the health system resources aligned to support productive interactions between patients and providers resulting in improved outcomes. The component restructuring included self-management supports, delivery system design, decision supports, clinical information systems, organization of health care, and community (Wagner, 1998). Elaborating on the work of Glasgow et al. (2001), Barr et al. (2003) presented an expanded CCM model where prevention and health promotion practitioners were included in the health teams to address social determinants of health. In this model, the components of care were restructured and delivered in both the health system and the community. Alongside this expanded model emerged an international adaptation titled the Innovative Care for Chronic Conditions (ICCC) Framework (Epping-Jordan et al., 2004; Nuno-Solinis et al., 2012). This model emphasized community roles in the continuity and coordination of care and on policies to support prevention and improved care, including financing the system (World Health Organization, 2002). In regions of the United States where low-income populations predominantly live, there are inconsistencies in medical care because of lack of medical resources and an abundance of negative drivers related to social determinants of health. We employed the ICCC Framework, using 1115 Waiver funding as a new financing system, to increase CCM for low-income Mexican American individuals with T2DM in one region of the United States where gaps in care have historically been filled by public health clinics and federally qualified health centers. This article presents an overview of each setting where program services are delivered, its core strategies within each setting, and promising results.
Program Design
Population Served
Addressing diabetes in the Rio Grande Valley of South Texas is hindered by low rates of health insurance, lower socioeconomic status, and other social drivers. T2DM prevalence among Mexican Americans in this region is estimated to be as high as 30% (Kendzor et al., 2014), and only 30% of the adult population have insurance (Fisher-Hoch et al., 2015).
Between 2013 and 2018, 5,852 adult individuals with poorly controlled diabetes living in the Rio Grande Valley were enrolled in a CCM program named Salud y Vida (SyV). The aim of the program was to reach individuals most in need and provide CCM support to achieve optimal health. Established by a school of public health, the program was delivered in partnership with clinics, the regional mental health authority, nonprofit organizations, and the local health information exchange to improve T2DM health outcomes.
Recruitment activities were led by full-time patient navigators colocated at the partner clinics who identified eligible participants either through medical staff referrals or lab result reports. Patient navigators also conducted community events and door-to-door recruitment.
The enrollment visit was conducted through an in-person interview that lasted approximately 1 hour. Participants provided demographic information, medical history including mental health status, physical activity levels, barriers to care, and eating habits. Validated tools included the BRIEF Health Literacy screening tool, The Godin-Shephard Leisure Time Physical Activity Questionnaire, and the Patient Health Questionnaires (PHQ-2 and PHQ-9) that screened for depression. Once enrolled, participants’ CCM included primary care services by their medical home as part of usual care and enhanced services through their participation in SyV, delivered in home and community settings (Figure 1).
Diabetes Care Beyond the Clinic
Metrics of success and promising results: Most participants were female (68%), averaging age 52, primarily Spanish speaking (69%), uninsured (77%), and unemployed (55%), with educational attainment of eighth grade or less (48%). The following stressors to care were commonly reported at enrollment: financial (38%), health-related/insurance status (31%), and familial issues (28%). The average HbA1C at enrollment was 10.13%.
Medical Care in Clinical Settings
Partner clinics continued to deliver primary care services to individuals enrolled in SyV. Two clinics implemented patient-centered medical home models to improve the delivery system design, which led to receiving patient-centered medical home Level 3 recognition. The other two clinics modified workflows and enhanced data management and standing orders for diabetes care including referrals to behavioral health care.
Metrics of success and promising results: Quality of diabetes care was assessed using the National Committee for Quality Assurance measure to assess diabetes care (NQF-0059). HbA1c poor control (>9%) was calculated according to the National Committee for Quality Assurance standards, which were also used by the Texas 1115 Waiver to approve performance-based payments. Collectively, the rate of patients with HbA1c > 9% was 28.84%; this performance level exceeded the high-performance level benchmark of 28.95% (lower percentage signifies better performance).
Addressing Social Drivers of Health in Home Settings
Once enrolled, participants received home visits for up to 2 years. These were provided by community health workers (CHWs), social workers (SWs), and behavioral health case managers.
Community Health Worker Home Visits
All participants were assigned a CHW who performed home visits quarterly, intermittent telephone calls, and text messaging. Participants were paired with CHWs based on language preference and home location. The role of the CHW was to bridge the gap between clinic and community services, working through patient navigators to communicate critical information to the medical care team to promote continuity of care and motivate positive health behavior change.
CHWs were equipped with a laptop, scale, blood pressure monitor, and HbA1C point-of-care kit to conduct measurements at every home visit along with handouts and educational tools for the participants. Visits comprised reviewing participants self-management practices such as healthy eating, physical activity, glucose monitoring, and medication adherence while employing motivational interviewing (MI) techniques to help participants overcome ambivalence, enhance motivation, and ultimately achieve diabetes-self-management. MI has proven effective in interventions targeting behavior change including diabetes management, with better outcomes observed in individualized approaches (Christie, & Channon, 2014). CHWs received 20 hours of MI training annually and were monitored by the MI master-trained CHW and a quality assurance coordinator who provided training, role-play practice, and feedback sessions.
CHWs also assessed barriers, including environmental (e.g., substandard housing, legal status, domestic violence, lack of transportation), financial (e.g., lack of resources for basic needs), and lack of social support systems. They connected participants to appropriate services to address identified needs.
Metrics of success and promising results: Home visits typically lasted 1.5 hours. In all, 89% of participants received at least one home visit. On average participants received 3.8 home visits. More than half of the participants (n = 3,132) established a goal related to nutrition and healthy eating (63%), physical activity/being active (16.2%), health coping management skills (9.2%), medication adherence (8.5%), and other (3.1%).
Social Worker Home Visits Address Financial Barriers
SW home visits were triggered by referrals from CHWs for financial needs. SW services included assisting participants with applications to social service programs (e.g., Medicaid, food pantry, indigent health care funding) as well as identifying support opportunities. They also managed a fund within the program that assisted with medical supplies, medication, and other needs, and worked with the participants medical home to coordinate these services.
Metrics of success and promising results: Since launching the financial assistance subprogram, a total of 629 cases were funded for diabetes-related supplies, and on average, participants received $140.
Behavioral Health–Focused Home Visitor
CHWs conducted behavioral health screening using the PHQ-9. Scores of 10 or greater or the identification of other mental health concerns triggered referrals to the behavioral health case manager. The case manager coordinated the triage visit with the region’s mental health authority for screening and treatment and provided home-based coping skills training for individuals who did not meet enrollment criteria for services. The home-based coping skills involved setting recovery goals, teaching effective coping techniques and skills for symptom management, and training on the identification of symptom triggers.
Metrics of success and promising results: Frequency of behavioral health screening varied from year to year. A total of 497 participants (8%) received the PHQ-9 at some point in the program. Of these, 58% had a score of moderate to severe depression. All participants were referred to behavioral health services for further evaluation.
Educational Services Provided in Community Setting
SyV provided diabetes self-management education (DSME) in community settings accessible to participants. Between 2013 and 2018, DSME consisted of six classes offered across 6 weeks and covered 11 learning objectives. Participants were encouraged to complete the full series during their first weeks in the program; however, it was available to participants to repeat. To promote compliance with class attendance, classes were available during various hours and on weekends. DSME instructors were trained using the Diabetes Empowerment Education Program curriculum. The unique structure of the instructor-supported DSME program was based on behavior change theory, incorporated hands-on activities, and was designed to be culturally and linguistically relevant for our priority population.
Metrics of success and promising results: In all, 75% of participants attended at least once class, 64% attended at least three classes, and 26% elected to repeat classes for additional support. In a sample of 453 participants whose knowledge of diabetes self-management was assessed pre- and post-DSME, 69% improved their knowledge scores.
Lessons Learned
The ICCC Framework provided structured and coordinated program elements that extended beyond the clinic, to the home and community settings. The program reached primarily low-income, uninsured Mexican Americans to address barriers to T2DM control and found promising results in clinical achievement measures, participation, and program reach. From the clinic’s perspective, SyV has influenced engagement in their medical home by continuously assessing the extent to which participants keep scheduled appointments, by providing solutions to factors that can improve appointment adherence, and by conducting reminder phone calls to ensure that participants attend or reschedule missed appointments.
Program Challenges
The program was not without its own challenges. To serve individuals across multiple settings with services provided by different organizations, having an efficient way to share information was essential. In the early stages of implementation, the program had no access to health information from the participant’s medical home. With assistance from the local health information exchange, the program now uses a population management platform that receives health information from clinics. Currently, half of the partner clinics are connected to this platform.
The strongest challenges faced by the program relate to addressing both social needs and social determinants of health. Some of the drivers addressed by the program included transportation; financial assistance for provider visits, labs, and medications; and access to food. There are many other drivers that are not able to be addressed, such as substandard housing, unemployment, immigration status, and domestic violence. Broader policy changes that affect the social determinants of health of the whole community and state are crucial. Although 1115 Waiver funding has been used to implement transformation projects such as the one described here, these do not resolve system-level barriers that result in disparities in health coverage, inequitable access, and ultimately poorer health outcomes.
Considerations for Implementation
The 1115 Waiver provided an opportunity to finance this work; however, there are key challenges to sustaining this expansion to CCM. Although health care funding is slowly moving toward value-based payments, much is still tied to services that happen within health care facilities or under guidance of a health care providers. Additionally, health care reimbursement for CHW services is not widely adopted by many health plans, state Medicaid programs, or Medicare. These factors affect the ability to finance a CCM model using this framework.
Other considerations for implementation included continuously monitoring and evaluating the processes that connect patients from the community back to the clinic. For example, in the initial phase of this program, the behavioral health screening by CHWs using the PHQ-9 was administered to participants who expressed emotional distress. However, after comparing PHQ-9 results obtained in the home with those obtained in the clinic, we expanded screening by administering the PHQ-2 to all participants. Results of 2 or higher triggered additional screening using the PHQ-9.
This framework involves continuously assessing social drivers of health. Organizations with interest in using this framework should consider the resources available to the program to ensure that both CCM support and social drivers are simultaneously addressed with participants. Implementing this model requires extensive case work and staff time to successfully address social needs and social determinants of health that contribute to health outcomes, especially in populations with inequitable access to resources.
In summary, the bridging of clinic, home, and community CCM using the ICCC Framework using CHWs provided opportunities to expand support for patients with T2DM. Our description of the framework expands the understanding of CCM approaches and contributes to further application of the framework in diverse settings.
Footnotes
Authors’ Note:
The authors gratefully acknowledge all the staff involved in the program particularly the community health workers delivering the main services to all the participants. We also thank all of our clinic and community partners for the support and collaboration. This work was supported by the Delivery System Reform Incentive Payment program through the Texas’s 1115 Medicaid Transformation Waiver.
