Authors: Jacob P. Tanumihardjo, Shari Kuther, Wen Wan, Kathryn E. Gunter, Kelly McGrath, Yolanda O’Neal, Cody Wilkinson, Mengqi Zhu, Christine Packer, Vicki Petersen, and Marshall H. Chin
This study sought to determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with Type 2 diabetes in a resource-constrained, frontier area. A quality improvement cohort study was conducted with patients with diabetes at St. Mary’s Health and Clearwater Valley Health (SMHCVH), located in Idaho, USA, between September 2017 to December 2021. The intervention implemented at SMHCVH integrated medical and social care through a population health team (PHT) including CHWs, where staff assessed medical, behavioral, and social needs with annual health risk assessments and provided core interventions including diabetes self-management education, chronic care management, and more. Patients with diabetes were categorized into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters. The primary outcome measures included HbA1c, blood pressure, and LDL levels over time for each study group. Results demonstrated that PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c levels of all PHT intervention patients (i.e., those with both one encounter and those with two or more encounters) significantly decreased from baseline to 12 months and reductions were sustained overtime. These findings suggest the SMHCVH PHT model can effectively improve HbA1c outcomes for people with diabetes, particularly those who face significant medical and social challenges, but rural and frontier communities will need more financial support to increase CHW engagement and care coordination under this model.
Link: New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals
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Resource Topic: CHW, Diabetes, Intervention
Resource Type: Research
Year: 2023
Region: North America (U.S. and Canada)
Country: United States of America
Publisher May Restrict Access: No