Community Programs Linked to Clinical Services

Resources for Diabetes and Hypertension

RESOURCES AND TRAININGS

Addressing Chronic Disease through CHWs: A Policy and Systems Level Approach, CDC Division for Heart Disease and Stroke Prevention
This document provides guidance on integrating CHWs into community-based efforts to prevent chronic disease and describes state policies, programs that engage CHWs, and resources to assist state health departments.

CDC 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.

Community Health Worker Training Resource for Preventing Heart Disease and Stroke
The Community Health Worker Training Resource for Preventing Heart Disease and Stroke (2015) is an evidence-based, plain-language training resource and reference for CHWs as well as a curriculum that health educators, nurses, and other instructors can use to train CHWs. The updated resource has 15 chapters that show how CHWs can help individuals prevent or manage heart disease, stroke, high blood pressure and cholesterol, diabetes, depression and stress, and other lifestyle risk factors. Also included are sections about working with children and teens and helping individuals talk to their doctor and take medicines properly.

Community Health Workers in Diabetes Management and Prevention, AADE Position Statement
The American Association of Diabetes Educators released a position statement addressing the involvement of Community Health Workers in diabetes self-management education (DSME).

Diabetes Educator Practice Levels
The American Association of Diabetes Educators has established Diabetes Educator Practice Levels which allow CHWs to be trained as Level 1 Associate Diabetes Educators and assist in DSME.

Engagement of CHWs in Diabetes Self-Management Education Programs Technical Assistance Guide, May 2015, CDC Communication to Grantees, May 20th, 2015
Provides guidance for states proposing to increase the engagement of Community Health Workers (CHWs) in the delivery and support of Diabetes Self-Management Education (DSME) programs.

Engaging Community Health Workers in Diabetes Self-Management Education Programs
This document provides an overview of a technical assistance tool developed by CDC staff to explain key drivers associated with engaging community health workers (CHWs) in diabetes self-management education (DSME) programs. It also highlights examples from three states that have done significant work in supporting the CHW workforce, including training, certification, and reimbursement initiatives. Finally, the document provides an illustrative example of one state’s work on each of the key drivers associated with engaging CHWs in DSME.

Integrating Community Health Workers in the Changing Health System
NACDD General Member Webinar June 25, 2015 Presentation by Haley Stolp (reflects author’s findings and NOT those of the CDC) Note: CHW presentation begins about 24 minutes into the recording.

Policy Evidence Assessment Report: Community Health Worker Policy Components, CDC Division for Heart Disease and Stroke Prevention
This report identifies 14 CHW policy components and assesses them based on the strength of supporting evidence (emerging, promising, and best). The examined components include team-based care, chronic care, scope of practice, and others.

Promoting Healthy Choices and Community Changes: An E-learning Program for Promotores De Salud
U.S. Department of Health & Human Services, Office of Minority Health’s Think Cultural Health (TCH) online resources and tools to promote cultural and linguistic competency in health care.

Proportion of recognized/accredited DSME programs in targeted settings using CHWs in the delivery of education/services

The purpose of this performance measure is to assess the extent to which DSME programs are engaging CHWs in the delivery of diabetes self-management education and service. There is a growing body of evidence supporting the role of CHWs in diabetes care. CHWs serve in a variety of capacities, typically focusing on strategies to improve diabetes self-management (Shah et al, 2013). Community health worker (CHW) interventions have been found to be a promising strategy for improving diabetes outcomes, especially among low-income and racial and ethnic minority populations (Hunt et al, 2011) Five main roles have been identified for CHWs including patient care, education, support for care delivery provided by other health professionals, care coordination, and social support (Norris et al, 2006) Engaging CHWs to deliver or help in the delivery of DSME Programs and to provide support services for diabetes self-management in targeted settings, can improve the diabetes outcomes of the vulnerable populations they serve.

Proportion of health care systems that engage CHWs to link adult patients with high blood pressure to community resources that promote self-management

The purpose of this performance measure is to assess access and quality of care in primary health care to include more diverse services such as education, coaching, social services, behavioral counseling through a care team that supports care coordination among providers and community and social service resources. Results from research and practice evidence show that CHWs can improve health outcomes when they are included in disease prevention and chronic disease management efforts for conditions like asthma, cancer, diabetes, cardiovascular disease, nutrition, and depression. CHWs help lower health care costs by reducing the number of emergency room visits and hospitalizations. CHWs have helped reduce barriers to care and treatment adherence (Brownstein et al., 2007; Brownstein et al., 2005; Martinez et al., 2011; IOM 2010).

Intermediate:

Proportion of patients with high blood pressure in adherence to medication regimens The purpose of this performance measure is to assess rates of antihypertensive medication (AHM) adherence among adult patients with high blood pressure, as an intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management. Support for new models of patient care, such as patient-centered medical home (PCMH) and accountable care organizations (ACO), is in part premised upon the potential for these models to encourage improved patient self-management and medication adherence (Bechtel and Ness, 2010.) Better medication adherence to AHMs reduces cardiovascular risk and improves health outcomes (Bitton et al., 2013; Bouchard et al., 2007; Corrao et al., 2011.)

Proportion of patients with diabetes in adherence to medication regimens

The purpose of this performance measure is to assess rates of medication adherence among adult patients with diabetes, as an intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management, such as community pharmacists and community health workers.

Rigorous reviews have found that adherence among persons with chronic diseases in developed countries averages only 50% (WHO 2003). Estimates for medication adherence rates among people with diabetes vary widely (31% to 98%), but most suggest substantial room for improvement (Cramer 2008, Odegard 2007, Rubin 2005). Nonadherence to diabetes medications is associated with poorer glycemic control and increased hospitalizations, health care costs, and mortality (Ho 2006, Odegard 2007, Salas 2009, Sokol 2005).

In low income populations, competing needs compound the challenges of improving health, including the problem of medication adherence (WHO 2003). Even within an insured population, disparities have been found in rates of cost-related medication underuse, with African Americans and Latinos more likely than whites and Asian/Pacific Islanders to report using less medication because of cost (Tseng 2008). Higher rates of cost-related medication underuse are also found among Medicaid recipients than among those with Medicare or private insurance (Piette 2004).

Number of participants in recognized/accredited DSME programs using CHWs in the delivery of education/services

The purpose of this performance measure is to assess the number of participants using DSME programs engaging CHWs in the delivery of diabetes self-management education and services. There is a growing body of evidence supporting the role of CHWs in diabetes care. CHWs serve in a variety of capacities, typically focusing on strategies to improve diabetes self-management (Shah et al, 2013). Community health worker (CHW) interventions have been found to be a promising strategy for improving diabetes outcomes, especially among low-income and racial and ethnic minority populations (Hunt et al, 2011) Five main roles have been identified for CHWs including patient care, education, support for care delivery provided by other health professionals, care coordination, and social support (Norris et al, 2006) Engaging CHWs to deliver or help in the delivery of DSME Programs and to provide support services for diabetes self-management in targeted settings, can improve the diabetes outcomes of the vulnerable populations they serve.

Proportion of patients with high blood pressure that have a self-management plan (including medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments)

The purpose of this performance measure is to assess the change in the proportion of patients with high blood pressure in health care systems/state that have a documented self-management plan to manage their high blood pressure. This change is an expected intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management of high blood pressure. Patient self-management of chronic hypertension has been shown to encourage lifestyle changes that mediate risks related to high blood pressure including weight loss and weight control, increased physical activity, decreased alcohol intake, and increased medication compliance (Fleischmann, 2004; Zarnke, 1997).

Long-term:

Decreased proportion of people with diabetes with A1C > 9

The purpose of this performance measure is to monitor changes in the proportion of people with diabetes with poor glycemic control (HbA1c > 9%) and at greatest risk of diabetes complications. The Diabetes Control and Complications Trial (DCCT Research Group, 1993), the UK Prospective Diabetes Study Group (Stratton et al., 2000) and subsequent clinical trials (Ismail-Beigi et al., 2010) found increased risk of microvascular complications (retinopathy and nephropathy), with higher HbA1c levels. To reduce the risk of complications the American Diabetes Association recommends a HbA1c < 7% with testing at least two times per year for those in control and quarterly for those not in control to reduce the risk of complications (ADA, 2014).

Proportion of adults with known high blood pressure who have achieved high blood pressure control The purpose of this performance measure is to ensure enhanced funded states have state-level access to aggregate data in order to quantify the achievement of blood pressure control among patients with known high blood pressure. The performance measure captures the NCQA clinical quality measure identifying the number of adults between the ages of 18-85 years old within the state that have achieved blood pressure control. There is evidence that heart attacks and initiation and recurrence of stroke can be prevented by adequately treating and controlling blood pressure (CDC, 2012).

1422 Component 2

Strategy 2.6: Increase engagement of CHW to promote linkages between health systems and community resources for adults with high blood pressure and adults with prediabetes or at high risk for type 2 diabetes (See also Diabetes Prevention the Health Systems Resource Guide).

Short-term:

Number of health systems that engage Community Health Workers (CHWs) to link patients to community resources that promote self-management of high blood pressure

The purpose of this performance measure is to assess health care system engagement in the promotion of self-management of high blood pressure through the use of Community Health Workers (CHWs). Research and practice evidence indicates that CHWs help reduce barriers to care and increase treatment adherence. Their inclusion in disease prevention and management efforts for chronic conditions, including cardiovascular disease, has been associated with improved health outcomes. Additionally, integration of CHWs into care delivery has been shown to lower health care costs by reducing the number of emergency room visits and hospitalizations (Brownstein et al., 2007; Brownstein et al., 2005; Martinez et al., 2011; IOM 2010).

Number of health systems that engage Community Health Workers (CHWs) to link patients to community resources that promote prevention of type 2 diabetes

The purpose of this performance measure is to assess health care system engagement in the prevention of type 2 diabetes via utilization of Community Health Workers (CHWs). Research and practice evidence indicates that CHWs help reduce barriers to care and increase treatment adherence. Their inclusion in disease prevention and management efforts for chronic conditions, including type 2 diabetes, has been associated with improved health outcomes.

Intermediate:

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program

The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Proportion of adults with high blood pressure in adherence to medication regimens.

The purpose of this performance measure is to assess the change in the proportion of adults adherent [i.e., proportion of days covered (PDC) value of 80% or higher as a measure of secondary adherence] with taking their antihypertensive medications (AHMs). The specifications outlined below for this measure involves use of the PDC methodology applied to administrative pharmacy claims data to assess adherence to renin angiotensin system antagonist (RASA) medications. Adherence to RASA medications can be used as a proxy for adherence to all AHMs. This method is supported by the Pharmacy Quality Alliance (PQA) and a similar method is used by the Centers for Medicare and Medicaid Services in their Star Rating methodology. Other methods to assess population-level AHM adherence can be used by the grantee, including use of clinical data, but they must first receive approval to do so by their CDC Evaluator.

Proportion of patients with high blood pressure that have a self-management plan (may include medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments)

The purpose of this performance measure is to increase the proportion of patients with high blood pressure who have developed and implemented self-management plans to monitor their blood pressure. Self-measured blood pressure monitoring (SMBP) plus additional clinical support is one strategy that is being promoted by healthcare and public health professionals to improve blood pressure control. SMBP broadly refers to the regular use of a personal blood pressure measurement device that is used by the patient outside a clinical setting (Uhlig K, Balk EM, Patel K, Ip S, Kitsios GD, Obadan NO, et al, 2012). Patient self-management of chronic hypertension has been shown to encourage lifestyle changes that mediate risks related to high blood pressure including weight loss and weight control, increased physical activity, decreased alcohol intake, and increased medication compliance (Fleischmann, 2004; Zarnke, 1997).