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Health Care Professionals' Perceptions of Community Health

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Health Care Professionals' Perceptions of Community Health 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 Health Care 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 Diabetes 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 Physicians Family Practice Cascade, Piedmont Healthcare, USA • Primary care 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 hospital 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 perprovides 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
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