Central Journal of Family Medicine & Community Health

Research Article *Corresponding author Andrea L. Cherrington, Department of Medicine, Division of Preventive Medicine, MT 612, 1720 2nd Professionals’ Avenue South, Birmingham, AL 35294, Tel: 205-996-2885; Email: Submitted: 12 February 2018 Perceptions of Community Accepted: 21 April 2018 Published: 23 April 2018 Health Workers’ Role in ISSN: 2379-0547 Copyright Management at a Community © 2018 Cherrington et al. OPEN ACCESS

Hospital Keywords • Community Health Workers 1 2 3 4 Wanda S. Gumbs , Brittany Payne , Robyn M. Davis , April A. Agne , • Diabetes Mellitus Type 2 and Andrea L. Cherrington4* • Minority health 1Piedmont Family Practice Cascade, Piedmont Healthcare, USA • 2Department of Internal Medicine, School of Medicine, University of Alabama at Birmingham, USA • Community health centers 3Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of • Patient Protection and Affordable Care Act Alabama at Birmingham, USA 4Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, USA

Abstract The Community Health Worker (CHW) model is increasingly implemented in diabetes management; little has been published about how health care professionals (HCP) view the role of CHWs in the healthcare team. The study’s objective is to examine HCPs’ perceptions of the CHW model. Nine semi- structured interviews were conducted with a convenience sample of HCPs at a community in Birmingham, Alabama. A trained interviewer, using a written guide, conducted telephone interviews. Interviews were audio taped, transcribed, and then coded by two independent reviewers using an iterative consensus process. Participants identified CHW roles including liaison, educator and mentor. Concern was voiced about CHWs’ ability to recognize limitations, provider time constraints, and lack of system resources and support. HCPs agreed that CHWs are assets to any healthcare team. However, most were unsure of how such an intervention could practically be implemented within resource-poor systems. Results suggest a need for the development of creative strategies to help vulnerable health systems.

ABBREVIATIONS and practitioners have turned to community health worker CHW: Community Health Worker; HCP: Health Care (CHW)-ledthe scientific interventions and public health to better sectors. connect Increasingly, high risk communities researchers Professionals; DTM: Diabetes Team Members; PCP: Primary Care with the health care system [7-10], and improve health outcomes Providers among underserved populations. While a growing body of INTRODUCTION literature supports the effectiveness of CHWs in improving diabetes self-care and glycemic control [7,11,12], less attention In the United States, diabetes has become an increasingly has been given to how the CHW model might best be implemented morbid and costly disease with 12.2% of adults living with diabetes so as to function harmoniously with ongoing clinical efforts. [1,2] and an estimated $176 billion spent on direct medical costs [3]. Effective disease management and glycemic control can CHWs, also known as lay health advisors or promotoras prevent or delay much of the morbidity associated with type 2 de salud, are lay individuals who promote health and proper diabetes [4]. However, few patients with diabetes achieve the nutrition, and work to improve health care and access to care by control needed to avoid these complications; further, minority providing services to individuals in the communities where they populations and individuals of lower socioeconomic status are at reside or serve [13,14]. While integration of the CHW into the disproportionately high risk for diabetes complications [5]. For health care delivery team represents standard of care in other underserved communities, limited access to health care services and educational resources, as well as differences in knowledge and depends on the nature of the particular health care system parts of the world, how this integration occurs is context-specific and beliefs about diabetes self-management, contribute to [15-21]. Roles of CHWs are often driven by a combination of poor disease control and worse outcomes [6]. Thus, translating individual and community needs [8,18,22]. For example, a recent effective management strategies proven in controlled trials in study of CHWs in four different cities in Brazil [17], demonstrated the challenges CHWs face when balancing their anticipated roles diverse community settings represents a significant challenge for Cite this article: Gumbs WS, Payne B, Davis RM, Agne AA, Cherrington AL (2018) Health Care Professionals’ Perceptions of Community Health Workers’ Role in Diabetes Management at a Community Hospital. J Family Med Community Health 5(3): 1149. Cherrington et al. (2018) Email: Central with the expectations of the communities they serve. The study conducted with health care professionals (HCPs) at a safety-net found that while CHWs in some cities acted as educators and care hospital that provides care to patients on an income-based sliding managers, in other towns, they took on more political roles acting scale. A qualitative study design was utilized because this method as mediators and advocates, largely due to community demands has been shown to be very useful in examining health services [17]. organization and policy, including providers’ clinical decision making, by exploring both the explicit and implicit routines and In the U.S., the CHW model has been steadily gaining rules used by providers [17]. This design also allowed for the recognition as a viable strategy for the prevention and discovery of authentic concepts based on the participants’ own management of chronic disease at the systems level [8,11,23,24]. For example, the CHW model has been increasingly recognized of the study itself or its instruments [22]. All study protocols and utilized in the primary care setting, as a key tool in the wereperceptions approved and byindependent the University of the of confines Alabama and at Birmingham’spresumptions patient centered medical home model [7,11,12,25]. Based on a Institutional Review Board. growing evidence base in combination with practical experience from longstanding CHW programs [26-29], major organizations Setting including the American Association of Diabetes Educators, the American Diabetes Association, the Centers for Disease As part of the Deep South, Alabama has a heavy diabetes Control and the Community Prevention Services Task Force burden with 14.6% of adults living with diabetes compared to have all endorsed the CHW model for diabetes management and the national average of 9.4% [39]. Since the 1990s, the burden of prevention [8,22,30-33]. Furthermore, the Patient Protection diabetes in Alabama has more than doubled [40]. It is estimated and Affordable Care Act of 2010 recognizes CHWs as important that in Alabama the total annual costs attributable to diabetes members of the healthcare workforce, and encourages their for adults 19 and older with diabetes is $8.5 billion or $16,828 utilization to promote positive health behaviors and outcomes in per person [41]. High rates of co-morbid conditions such as th rd medically underserved communities [13,34,35]. This legislation hypertension and obesity (Alabama ranks 4 and 3 in the nation, also takes steps towards provision of funds to support these respectively) compound the challenges of diabetes management initiatives. [40]. In Jefferson County, approximately 11% of residents are uninsured [39]. At the time the study was conducted, diabetes- Still, tensions exist. As stakeholders wrestle with how best to implement the CHW model either alongside or as part of primary was 50% higher for African American compared to whites [42]. care, questions arise. For example, there is concern both among Thespecific safety mortality net hospital in Jefferson involved County in this was study 14.0 per provides 100,000, care and to health care professionals (HCPs) and CHWs about training, roles residents of Jefferson County based on a sliding scale. While an and responsibilities, funding and compensation [11,22]. CHWs, internal assessment revealed that the nearly 700 patients had in particular, have voiced concerns about whether they will been referred for diabetes education in the previous year, only receive adequate support from health care professionals and the 19% completed the 2-session (9 hours total) course, and many reassurance they need in order to feel competent doing their jobs, never attended a single session suggesting that programs to to feel welcomed as a part of the health care team [16]. In a study improve engagement and better link patients to vital education in Brazil, Grossman-Kahn and colleagues highlighted ‘failure to services were sorely needed. be fully integrated into the primary care team’ as a key obstacle to implementation of the CHW model [36]. Another recent study Sample A convenience sample of nine health care professionals of leaders who champion the model and clinic culture as key treating patients in the outpatient clinics of a local urban safety- conducted among programs in Minnesota identified the presence facilitators to successful use of the CHW model [37]. Clearly, net hospital were recruited to participate. Potential participants understanding how providers and other health care professionals were contacted by phone and invited to participate. HCPs were view the role of CHW as part of the health care delivery team is recruited from two groups: 1) primary care providers (PCPs) and vital but to date there is scant literature on the topic. 2) diabetes team members (DTMs) all of whom support patients This study is part of a larger project, Diabetes Connect, aimed in the management of their disease. Five PCPs participated, four physicians and a assistant. DTMs interviewed had a of the health care team, in diabetes prevention and management variety of roles that coordinate care for patients with diabetes [38].at promoting This study the efficient examined integration the perceptions of CHW efforts of health with those care including a case manager, pharmacist, diabetes educator and professionals of the roles of CHWs within a community hospital nutritionist, and social worker. setting, the value of the CHW model in diabetes prevention and Health Care Professional (HCP) Interviews management, and the limitations of the current to implement such a model. This perspective is critical if we are Interviews were conducted August 2011 to January 2012. to promote CHWs as an integral part of the health care delivery Once an individual agreed to participate in the study, informed team. consent was obtained to conduct a telephone-based semi- structured interview. The content and structure of the interview METHODS guide were developed based on relevant literature regarding Study design CHW roles in the context of chronic disease management [12]. The interview was preceded by a brief questionnaire to gather Individual qualitative semi-structured interviews were basic demographic information about the participant and to

J Family Med Community Health 5(3): 1149 (2018) 2/8 Cherrington et al. (2018) Email: Central understand their practice setting. Each interview question of participants. The majority was female and seven of nine was preceded by a short synopsis of the rationale related participants were aged 41years or greater. PCPs had practiced on to the question. The questions focused on topics including average for 20 years. patient barriers, familiarity with the CHW model, CHW roles, responsibilities and limitations, CHW education and training, support for CHWs, HCP’s interaction with CHWs and as well as involvement in diabetes prevention and management. Many of Four broad categories of themes were identified in CHW barriers to implementation of the CHW model (Table 1). themes were consistent between both groups of HCPs, including patient and community needs, CHW roles and responsibilities, Data analysis limitations of CHW involvement in patient care, limitations of Interviews lasted approximately 30 minutes, were audio- the hospital system to support integration of the CHW model, recorded and transcribed verbatim by an independent, off-site and. transcription service. Data has been anonymized and identifying the two groups. For example, PCPs also presented issues such information has been removed from participant responses to Additional themes were identified that varied between protect the participants’ identities. Because investigators believed the potential for intrinsic barriers to limit the effect of well- PCP perceptions might differ from other HCPs, the analysis of intentionedas specific barriers interventions. to provider While DTMs interaction introduced with ideas CHWs, about and the importance of CHW compensation and the need for consistent care providers (PCPs) included physicians and a physician communication with CHWs, and integration of CHWs into the assistant,interview transcripts and 2) diabetes was stratified team members into two (DTMs)groups: 1) included primary a health care team. social worker, all of whom support patients in the management Community needs and opportunities for CHW ofcase their manager, disease. certified For each diabetes group, an educator, initial transcript a nutritionist, was read, and involvement independently coded by two investigators, and then discussed line-by-line until 100% consensus was achieved on each code. HCPs recognize that factors outside of the clinical setting Codes were revised and added as subsequent transcripts were present barriers to patient utilization of any intervention and subsequent adherence with a treatment plan. four major categories of themes and grouped codes under these “Now that we have [a diabetes] program up and running we reviewed, using an iterative consensus process. We identified categories. have people in place to give it, the barriers the patients face are can In order to validate results, we employed three of the four they get off work, do they have transportation? … And then [what about] the ones that have learning disabilities, or who are blind, or who speak another language? So there [are] some resources but wereverification presented techniques before aof panel qualitative of peers research, for their as input, described and the patient still has to work on our timeline, rather than us being disagreementsby Cohen [43]. on Namely, codes were1) peer decided review: by preliminary a third independent findings available to them.” PCP 1 reviewer; 2) member checking: we held a discussion group “And sometimes the patients are too embarrassed to ask [the and tested our interpretations and conclusions against their PCP] to explain what they’re saying.” DTM 4 perspectiveswith study participantsand intentions; where and 3) we external described auditing: our findingsthrough In addition, providers acknowledge the need to reach patients to help with education, motivation, and access to resources. They independent researchers to evaluate the accuracy of the research suggest that CHWs could help meet these needs by utilizing poster presentations at several scientific meeting, we allowed culturally sensitive strategies in their approach to patients, and [43]. Finally, we employed the use of rich quotes to ensure that by having a working knowledge of community resources that are wedesign, provided and determine an accurate, if our meaningful findings were account supported of the by complexthe data accessible to patients. perspectives and realities studied [43]. “We have some dietary counseling for [patients]. We even have RESULTS a diet class for them to go to. I think the problem is they have to be Table 2 summarizes the demographic characteristics motivated to enough to attend them. We give them the information,

Table 1: Sample Provider Interview Questions. Domain Related Questions What barriers do your patients face when trying to obtain diabetes education? Could you identify or describe some key factors that don’t allow them to receive diabetes education? Perceived patient barriers • What types of access do your patients have to diabetes education resources in languages other than • English? • In your practice, have you ever worked with or shared a patient with a community health worker? Knowledge of CHWs Have you ever heard of community health worker? • In your opinion, what is the single best role a CHW could play in helping patients prevent diabetes? Perceived CHW roles, responsibilities • When you hear about a CHW, what sort of role do you envision that person doing? and limitations • What activities related to diabetes prevention do you feel are inherently outside the scope of work for • a CHW? System support for CHWs and potential • In what ways, do you think the health system could provide support for the CHWs? barriers to their integration What do you perceive would be barriers, to creating a support system for the CHWs? • • J Family Med Community Health 5(3): 1149 (2018) 3/8 Cherrington et al. (2018) Email: Central

Table 2: Health Care Professionals’ characteristics (N=9)* at a be a teaching but also a kind of more than teaching, more than community hospital in Alabama. teaching kind of a mentoring you know where they’re going to Primary Care Diabetes Team come back to them and lead them through the process.” PCP 1 Characteristic Providers (n=5) Members (n=4) “[Assist patients] with basic changes. A lot of patients don’t Age Category even know about eating portion sizes, or eating late at night. I 31-40 2 - mean, this is stuff that you don’t need a degree to teach the patient 41-50 2 2 to do right.” PCP 3 51-60 1 2 CHW value: DTMs voiced concern about CHWs’ time and Gender felt the CHWs should be paid. Receiving payment would ensure Female 2 4 commitment. Male 3 - “Money and their time. If you want somebody to volunteer [as Ethnicity a CHW], if they volunteer they’re not going to be able to give you a lot of time.” DTM 2 Black 2 2 White 3 2 Views on training, education and CHW interaction Training with HCPs MD 4 - CHW education and training: PA 1 - in which CHWs should be competent, including, recognizing medical emergencies, preventive HCPs care identified practices, a common list of topics co- RN, CDE - 1 morbidities and medications. Additionally, PCPs want to ensure RD, CDE - - CHWs understand what living with diabetes is like and suggested MSW - 1 Associate - 1 hand. that CHWs shadow someone living with the disease to see first- Mean years in practice (range) 20 (10-35) - “Well hopefully we’ve talked with the patient about preventive *data collected in Aug. 2011 to Jan. 2012 care but it doesn’t always get addressed so probably [CHWs] need to be aware of what kind of preventive care the patient should be but they’re not following through with it.” PCP 3 doing too.” PCP 1 “I think the [CHW could] help support the individual in “Instead of just depending on the patients… checking their own specifically what they need to do.” blood sugar, [the CHW] may say, well, I’m going to make a home visit, uh, weekly, or so many times, to actually go and actually check DTM 1 the sugar yourself with the patient, not relying on their reading.” “So I can see [the CHW], doing some type of physical activity PCP 3 group with patients and … calling and motivating these folks to “CHWs could give [patients] information on recognizing come and participate.” DTM 2 diabetic emergencies like hypoglycemia, if the patient is having that problem [the CHW] need[s] to refer them to the doctor and Perceived benefits of the CHW model and potential make sure somebody helps them address it so that they don’t have roles problems.”PCP 1 CHW roles and responsibilities: “It would be good for community health advisors to walk through a day with these patients and see what they actually run all of which focused on activities theyPCPs felt and wereDTMs outside identified of into just trying to take care of diabetes.” PCP 1 theirfive roles own for scope CHWs of practice. in diabetes Roles prevention included and liaison, management, educator, facilitator, mentor and cheerleader (Table 3). Educator was the CHW limitations: would require assurance, including, patient privacy issues and both patients and providers. CHW responsibilities ranged from the ability of CHWs to PCPs recognize described their limitations. specific concerns Medication that identifyingmost commonly patient identified barriers role, and and in turn, involves communicating interaction them with and treatment plan adjustments were the most common activity with providers, to recognizing when to refer patients to their doctors. represented the greatest area of concern among providers with implementingidentified as such outside a program. the scope of CHW activities and also “I know that [CHWs] go out in the community and educate and assist in providing resources and things like that for clientele.” DMT “One of my concerns would just be quality control. Making sure 2 the [CHWs] are adequately trained themselves, and that there’s some way to monitor at some level what they’re doing. Because I “[CHWs] turn education into fun. Not only are they learning, can see people [CHWs] being empowered to do this and going out but they’re sharing with otherpeople their experiences.” DTM 4 into left field, on their own.” PCP 4 “I guess their role would be getting out to the community, let “I would not like to have them telling [patients] how to adjust them know of places they can go and ways to just a…so it would their medicines. That would make me uncomfortable and hopefully

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Table 3: Health Care Professionals’ Perceptions of Community Health Workers’ Roles, Responsibilities, CHW Limitations, and Barriers to Systemic Support (n=9). Domain Themes Liaison Educator CHW roles • Facilitator • Mentor • Cheerleader • Identify and communicate key patient barriers to providers • Facilitate exchange of information between patients and providers • Teach patients about diet, exercise and preventive care • Educate providers about culturally sensitive issues • Facilitate patient follow-up CHW responsibilities • Identify community resources • Serve as long-term support for patients • Help guide patients through process of change • Help patients adapt their habits • Recognize when to refer patients to PCPs or HCPs • Should avoid medication or treatment plan adjustment CHW limitations • Recognize and adhere to HIPAA guidelines • Should not offer medical advice • • System budgetary constraints Systemic bureaucracy/red tape Barriers to CHW Integration • Provider time constraints • Skepticism about CHW usefulness • Lack of knowledge about and experience with CHWs • • make them uncomfortable too.” PCP 1 groups voiced concerns about lack of working experience with “Treatment plans will change. So treatment plans [would] be CHWs;specifically skepticism voiced concernsabout CHW about usefulness time constraints. and lack ofBoth system HCP outside the scope. Medication management would be outside the support for the work of CHWs. scope.” DTM 3 “The thing with physicians that would be challenging is just HCP interaction with CHWs: time, and finding some way-assuming there would be more than circumstances and settings in which CHWs would have direct one patient and there might be more than one advisor- from a interaction with the healthcare team;PCPs offered most werespecific, limited limited to practical standpoint, how to communicate information directly to patient problems. Conversely, DTMs demonstrated a willingness a physician is going to be a challenge.” PCP 4 to meet with CHWs on an ongoing basis. They expressed an interest in receiving updates on patients as well as gauging the “That would depend how much time that was going to take. If interpersonal skills of CHWs, wanting to ensure certain they are that added significantly to the limited time I have with the patient, I’m not sure that it would be helpful.” PCP 1 a good“If there’sfit for thesome community program theythat [aserve. patient] is enrolled in where “Well, one of the barriers, just offhand, [would be] just working there is some expectation to have a behavioral change, it would be through the [health] system’s red tape.” DTM 4 good to have some feedback [from CHWs] as to how that’s going…a “You know it’s a good idea [to have CHWs], it’s just that in this simple report on that would be helpful but not necessarily a direct setting, it’s going to be very difficult.” PCP 1 interaction.” PCP 4 PCPs was skeptical about how cost- effective the intervention “I don’t want someone standing at my desk really and I don’t would be over time. necessarily want to do weekly meetings or monthly meetings [about] the health care plan. I would rather it be something like “So, it, that’s that, and when you have a health care team like getting something in periodically or if the advisor found something that with a [CHW] and a medical provider that’s money too because alarming, then they contact me but on a case by case, as needed you got to pay for the [CHW].” PCP 2 basis, as opposed to a scheduled meeting.” PCP 2 “If you had a system where you had these community health “I would like for us to sit down and find out what that person’s workers, you could maybe have weekly meetings with them or strength were, the patient’s strengths…how community advisors monthly meetings…kind of like case management. It makes sense think that they could help that person more… Like what happened, to me; it seems like it would be time consuming and I’m not sure what occurred and what seems to work...” DTM 3 how cost-effective it would be.” PCP 2 Potential barriers to implementation of a CHW program: DISCUSSION HCPs recognized that inherent in the health system design, there This study used qualitative methods to assess health care are certain issues that could hinder interaction with CHWs. PCPs

J Family Med Community Health 5(3): 1149 (2018) 5/8 Cherrington et al. (2018) Email: Central professionals’ (HCPs) perceptions about the implementation of southeast and the data should thus be interpreted with caution. the Community Health Worker (CHW) model, and role of CHWs Provider perceptions regarding CHWs were likely framed based in diabetes prevention and management among their patients, on their experiences working in a resource-limited system that at a local safety net hospital. Analysis of the interview data serves a low-income and minority patient population and that does not employ CHWs. Therefore, these views may not be shared responsibilities of CHWs, and these ideas were fairly consistent by providers in other areas or settings. amongrevealed participants. that HCPs had Four very major specific categories ideas about of themes the roles emerged and CONCLUSIONS AND IMPLICATIONS and CHW roles, CHW limitations and support, patient and system Health Care Professionals agreed that Community Health barriersregarding to implementation implementation, of andthe CHW CHW model: training program and interaction benefits Worker involvement in diabetes prevention and management with the healthcare team. In general, HCPs recognize the importance of CHWs and can unsure of how such an intervention could practically or effectively beprograms implemented has multiple within potential a resource-limited benefits. However, system. They most also are them, about cultural competence and patient barriers. However, highlighted several important roles for CHWs that would theyimagine also how have they real could concerns both benefitabout utilizing their patients, the CHW and model educate in potentially help to bridge the information gap between them the context of chronic disease. Because of the nature of CHWs and their patients, leading to improved adherence to treatment as ‘lay’ individuals, and the uncertainty of the CHW education plans and subsequent improvement in health outcomes for their and training, primary care providers wonder if CHWs will know patients. program development, policy and research. Programs wishing to and act within their boundaries. These themes expand on These findings have several implications for future and are consistent with prior studies investigating providers’ implement a CHW model will need to develop creative strategies perceptions of CHW and their incorporation into clinical to elicit and incorporate health care providers’ concerns and teams. For instance, in a CHW-led diabetes education program expectations in order to enhance buy-in and create synergy evaluation, providers had concerns regarding CHWs’ ability to within the healthcare team. Many states have been implementing recognize clinical boundaries and understanding when to ask legislation and regulations to incorporate CHW models into their for help. Despite this concern, providers agreed with the notion health care programs, however there are still many health care that primary care coordination models utilizing CHWs could be providers unfamiliar with the model [29]. While CHW training programs vary from state to state, cross-training CHWs and to both build a trusting relationship and spend additional time HCPs on each others’ respective roles and value will enhance a forbeneficial diabetes in chronic education disease outside management, of the clinician’s noting CHWs’ visit [44,capacity 45]. programs’ effectiveness. Extension For Community Healthcare Providers also recognized CHWs’ ability to provide practical Outcomes (ECHO) is an innovative program that already employs strategies to overcome systematic barriers to healthcare and a model of distance education via video teleconferencing to train adherence to medication regimen. and support both health care providers and community health workers in medically underserved areas [48]. Such a program Although evidence regarding provider views on CHW could provide a platform for training on interdisciplinary and integration with the healthcare team is limited, existing evidence team based care the includes CHWs as key team members. Future suggests that successful programs need a physician champion, studies should focus on the development of generalizable models who can help with implementation of the system and increase for the implementation of CHW models into a variety of clinical buy-in among the other members of the healthcare team [20- settings that emphasize simultaneous integration with the health care team and respect for the value CHWs bring as trusted models are currently being explored. Provider behavior, such as individuals embedded in community [49]. 22]. Factors influencing successful implementation of CHW facilitate integration into a healthcare system [46]. Additionally, CONFLICTS OF INTEREST AND SOURCE OF culturalreferrals competencyto CHWs, can training be influenced among by health processes care designed providers to FUNDING and organizations serving minority communities may be a complementary approach to health care delivery for diverse This project described was supported by the University of groups as it enhances appreciation of CHWs’ trusted role and AlabamaAll authors at Birmingham’s declare that (UAB) they have Diabetes no conflict Research of interest. Center ability to bridge the gap between clinic and community [47]. [Award Number P30 DK-079626] from the National Institute Furthermore, providers’ attitudes about implementation of of Diabetes and Digestive and Kidney Diseases. The content is the CHW model likely stem from working in a system that is so solely the responsibility of the authors and does not necessarily overwhelmed, that the thought of adding something new, even something good, is viewed with skepticism. Ironically, it is those and Digestive and Kidney Diseases or the National Institutes of Health.represent Funding the official was alsoviews provided of the National by grants Institute from the of American Diabetes resources who employ disease management specialists, such as clinics that may stand to benefit the most. Clinics with enhanced Diabetes Association [191605] (Dr. Cherrington) and the Agency for Healthcare RQ [K12 HS019465] (PI Saag/Project PI Dr. CHWs comparatively speaking [44]. diabetes educators, may derive less benefit from integration of Cherrington). LIMITATIONS REFERENCES Results in this study were elicited from a small convenience 1. National diabetes statistics report: estimates of diabetes and its sample at a single hospital located in an urban setting in the

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Cite this article Gumbs WS, Payne B, Davis RM, Agne AA, Cherrington AL (2018) Health Care Professionals’ Perceptions of Community Health Workers’ Role in Diabetes Man- agement at a Community Hospital. J Family Med Community Health 5(3): 1149.

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