Abstract
ObjectiveTo compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients’ experiences of chronic care.Data sourcesClinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation.Study designA three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects.Principal findingsPatients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs.ConclusionsDiabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.
Highlights
The effectiveness of team-based models of primary care that include registered nurse care management [1] and pharmacist-led medication management [2] in improving diabetes care quality and patient self-management is well established
Diabetes care improved in community health centers (CHCs) integrating community health outreach workers (CHWs) and medical assistants (MAs) onto primary care teams, but the improvements were no different than improvements observed among matched control group patients
Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices
Summary
The effectiveness of team-based models of primary care that include registered nurse care management [1] and pharmacist-led medication management [2] in improving diabetes care quality and patient self-management is well established. These models for managing diabetes care are not financially feasible for many community health centers (CHCs) that serve low-income patients [3]. Team-based models that involve patient panel management by medical assistants (MAs) and/or community-based care management by community health outreach workers (CHWs) are relatively more financially feasible for CHCs to adopt and implement. Previous research has demonstrated the patient health benefits of diabetes education, especially programs and interventions that emphasize patient self-management for vulnerable patients [6, 7], and MAs and CHWs can provide self-management support to diabetic patients and change patient knowledge and behavior and, in some instances, health outcomes [8,9,10]. The potential positive impact of MA health coaching and panel management interventions on patient outcomes and experiences of care in underserved settings highlights the promise for expanding MA responsibilities to support diabetes care management [14,15,16,17]
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