Diabetes Improves After Health Worker, Pharmacist Intervention

One-third of 986 patients achieved long-term self-care of their type 2 diabetes after building trusting relationships with community health workers, according to a new study. Similar results have been realized when pharmacists are involved in patients’ diabetes care.

In the University of Texas (UT) Health Science Center at San Antonio study, published in the Annals of Family Medicine,¹ patients were recruited to the study prior to the COVID-19 pandemic from a primary care practice at University Health’s Robert B. Green Campus in San Antonio and through physician referrals.

Then, 10 health care workers (called promotor or promotora in Spanish) from the primary care practice visited patients’ homes to gather more information about their diabetes and their needs over a four-year period. They spoke to patients in Spanish, if patients chose.

“So, they send me a patient, I assign a promotor or a promotora, and they go and knock at the patient’s door, and they say, ‘I’m coming here because the doctor cares about you. We want to understand you’,” said Carolina Gonzalez Schlenker, MD, MPH, second author of the article and assistant professor at UT Health San Antonio’s Joe R. and Teresa Lozano Long School of Medicine, in a news release.² “And they do this authentically, and the patient feels the authenticity of the caring but also, the visit is not under the tick-tock of an accountant. Trust building can’t be billed by the hour.”

Notably, 32.4% of participants achieved “self-care generativity.” The patient in this classification plans self-care and progresses through milestones such as lowering the hemoglobin A1C, said study first author Robert L. Ferrer, MD, MPH, professor of family and community medicine at UT Health San Antonio. Ferrer is an expert on social determinants of health status in Hispanic populations.

In addition, 40.5% progressed to a stage called “stabilization” in which the patient and community health worker address obstacles to self-care together. “However, the patient in this group has stopped short of making the transition to self-care and continues to need help with problem-solving,” said Carlos Roberto Jaén, MD, PhD, senior author, professor and chairman of family and community medicine in the Long School of Medicine and with UT Health.

Around 27% of participants remained in “outreach.” They agreed to meet face-to-face with a community health worker, but did not advance toward creating an alliance of care, UT Health said. “They make a plan with the promotores, but it falls through. We never really do the intervention, and then they come back years later, and maybe they need an amputation,” Schlenker said.

Those who advanced to “self-care generativity” had sustained A1C reductions and fewer hospitalizations and emergency department visits than the other 2 groups.

“The intervention was only 12 weeks long and yet the effect was apparent 4 years later,” Jaén said.

“Patients have many reasons to distrust the health care system,” Schlenker said. “So, you plug in a trust builder, a promotor or promotora, who becomes a bridge between what makes sense in primary care and what makes sense to the patient.”

Physicians in busy practices require more information about patients than they can obtain in a 15-minute appointment, Schlenker noted. “This includes understanding life circumstances that hinder the patients from following what they are supposed to do for their type 2 diabetes,” UT Health said.

Community pharmacist intervention in patients’ self-management has also been shown to be effective in helping diabetic and pre-diabetic patients.

More than 45 pharmacies participate in the CDC-recognized National Diabetes Program (DPP), with assistance from the National Community Pharmacists Association (NCPA).

The first 10 participating pharmacies have had notable results, helping people with diabetes or prediabetes lose an average of 7% of their initial body weight, or 16 pounds, on average, said Carlie Traylor, PharmD, director of Strategic Initiatives and Student Affairs at NCPA.

Mathes Pharmacy in New Albany, Indiana—which has specialized in helping those with diabetes as a designated Diabetes Education Program for more than 10 years—expanded its services in 2020 to include the DPP.

A diabetes educator meets weekly with people with prediabetes to discuss nutrition, stress management, exercise, sleep hygiene, support systems, and other factors that contribute to the disease.

In its first DPP group, all participants lost weight, and no one was diagnosed with diabetes while in the program. Nine out of 17 participants who finished the program met their weight loss goal of at least 5%, while one participant lost 18% of their original weight.

References

1. Ferrer R, Gonzalez Schlenker C, Cruz I, et al. Community health workers as trust builders and healers: A cohort study in primary care. Annals of Family Medicine. 2022, 20 (5) 438-445; doi:10.1370/afm.2848

2. Diabetes self-care reached by 32% who built trust with community health workers, study finds. News release. The University of Texas Health Science Center at San Antonio. September 26, 2022. Accessed October 4, 2022. https://www.eurekalert.org/news-releases/965830