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Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.

ABSTRACT: BACKGROUND:We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits. METHODS:We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models. RESULTS:Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (-?0.56%) than non-COPE participants (+?0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (-?10.58?mg/dl) compared to the non-COPE group (-?3.18?mg/dl) for a difference in differences of 7.40?mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06?mmHg) than non-COPE patients (0.61?mmHg). We noted no significant change for body mass index in either group. CONCLUSION:Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population. TRIAL REGISTRATION:Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.

SUBMITTER: Trevisi L

PROVIDER: S-EPMC6880375 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.

Trevisi Letizia L Orav John E JE Atwood Sidney S Brown Christian C Curley Cameron C King Caroline C Muskett Olivia O Sehn Hannah H Nelson Katrina A KA Begay Mae-Gilene MG Shin Sonya S SS

International journal for equity in health 20191127 1

<h4>Background</h4>We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits.<h4>Methods</h4>We abstracted routine clinical data from the Indian Health Servi ...[more]

PMID: 31771603

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Project description:OBJECTIVE:To understand providers' opinions about the Community Outreach and Patient Empowerment (COPE) Project designed to strengthen Navajo Community Health Representative (CHR) outreach to individuals living with diabetes. DESIGN:This was a qualitative study nested within a larger evaluation of a programme intervention. SETTING:The study took place in Navajo Nation and evaluated a programme initiative designed to strengthen collaboration between CHRs and clinic-based healthcare providers and provide structured outreach to individuals living with diabetes in Navajo Nation. The CHR Programme is a formal community health worker programme that exists in most tribal healthcare systems across the USA. PARTICIPANTS:Healthcare providers involved in the programme took part in one-on-one interviews. ANALYSIS:We used thematic analysis for this study. A team of three study staff used open-coding to create a codebook. Coded material were summarised and patterns were identified and tied into a narrative using concept mapping. The study design and instrument construction were guided by a Community Health Advisory Panel. RESULTS:A total of 13 interviews were completed. Providers acknowledged CHRs as an asset to the clinical team and were enthusiastic about the COPE coaching materials, mentioning they provided a consistent message to CHRs and the community. Providers that led COPE trainings with CHRs valued the face-to-face time and opportunity to build relationships. Providers (n=4) supported CHRs' access to electronic health record to record patient visits and streamline referrals. Among their requests were having designated personnel to manage referrals with CHRs and a formal system to record modules CHRs have completed. CONCLUSION:Providers participating in COPE activities valued the work of CHRs and endorsed further strengthening relationships and communication with CHRs. Healthcare programmes should consider systems changes to integrate community health workers into clinic-based teams. TRIAL REGISTRATION NUMBER:NCT03326206; Results.

Project description:BackgroundCommunity Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturally-appropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation.MethodsSeven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes.ResultsClients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management.ConclusionThe COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients' families may foster these relationships and improve health outcomes.Trial registrationclinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).

Project description:BACKGROUND:Navajo community members face high rates of diabetes mellitus and other chronic diseases. The Navajo Community Health Representative Outreach Program collaborated with healthcare providers and academic partners to implement structured and coordinated outreach to patients living with diabetes. The intervention, called Community Outreach and Patient Empowerment or COPE, provides home-based health coaching and community-clinic linkages to promote self-management and engagement in healthcare services among patients living with diabetes. The purpose of this study was to evaluate how outreach by Navajo Community Health Representatives ("COPE Program") affected utilization of health care services among patients living with diabetes. METHODS:De-identified data from 2010 to 2014 were abstracted from electronic health records at participating health facilities. In this observational cohort study, 173 cases were matched to 2880 controls. Healthcare utilization was measured as the number of times per quarter services were accessed by the patient. Changes in utilization over 4 years were modeled using a difference-in-differences approach, comparing the trajectory of COPE patients' utilization before versus after enrollment with that of the control group. The model was estimated using generalized linear mixed models for count outcomes, controlling for clustering at the patient level and the service unit level. RESULTS:COPE enrollees showed a 2.5% per patient per quarter (pppq) greater increase in total utilization (p?=?0.001) of healthcare services than non-COPE enrollees; a 3.2% greater increase in primary care visits (p?=?0.024); a 6.3% greater increase in utilization of counseling and behavioral health services (p?=?0.013); and a 9.0% greater increase in pharmacy visits (p?<? 0.001). We found no statistically significant differences in utilization trends of inpatient, emergency room, specialty outpatient, dental, laboratory, radiology, or community encounter services among COPE participants versus control. CONCLUSIONS:A structured intervention consisting of Community Health Representative outreach and coordination with clinic-based providers was associated with a modest increase in health care utilization, including primary care and counseling services, among Navajo patients living with diabetes. Community health workers may provide an important linkage to enable patients to access and engage in clinic-based health care. TRIAL REGISTRATION:NCT03326206, registered 10/31/2017, retrospectively registered.

Project description:Background:American Indians and Alaska Natives experience diet-related health disparities compared with non-Hispanic whites. Navajo Nation's colonial history and remote setting present unique challenges for healthy food access. Objective:This study aims to understand the impact of the Healthy Navajo Stores Initiative (HNSI) on fruit and vegetable purchasing on Navajo Nation. Methods:We conducted a cross-sectional survey of 692 customers shopping at 28 convenience stores, trading posts, and grocery stores on Navajo Nation. Individual- and household-level sociodemographic data and food purchasing behaviors were collected. Descriptive and bivariate analyses for customers' individual- and household-level characteristics were conducted using chi-squared tests. The impact of individual-, household-, and store-level factors on fruit and vegetable purchasing was assessed using multiple logistic regression modeling. Results:Store participation in the HNSI was significantly associated with customers' purchase of produce. Customers experienced 150% higher odds of purchasing produce if they shopped in participating stores, compared with nonparticipating stores (P < 0.001). Store type was strongly associated with customers' purchase of fruits or vegetables. Customers shopping at a grocery store had 520% higher odds of purchasing produce than did customers shopping at convenience stores (P < 0.001). Customers shopping at trading posts had 120% higher odds of purchasing fruits or vegetables than did customers shopping at convenience stores (P = 0.001). Conclusions:Our findings reveal increased produce purchasing at stores participating in the HNSI. Customers were significantly more likely to purchase fruits or vegetables in stores enrolled in a healthy store intervention than in nonenrolled stores, after controlling for quantity of produce stocked and store type. Customers shopping in grocery stores and trading posts were significantly more likely to purchase produce than customers shopping in convenience stores. These findings have implications for food access in rural tribal communities.

Project description:ContextTo promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.ObjectiveTo characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.DesignLongitudinal study assessing funded wellness projects from tax inception through 2019.SettingThe Navajo Nation.ParticipantsOne hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.Outcome measuresThe categories and specific types of wellness projects and funding over 4 years by region and community size.ResultsOf revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.ConclusionsThrough 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

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Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.

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Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.

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