Diabetes Management: Interventions Engaging Community Health Workers
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends interventions that engage community health workers to help patients manage their diabetes. These interventions have been shown to improve patients’ glycemic and lipid control and reduce their healthcare use. Economic evidence indicates these interventions are cost-effective.
Interventions engaging community health workers in diabetes management are typically implemented in underserved communities and can improve health, reduce health disparities, and enhance health equity.
The CPSTF has related findings for interventions that engage community health workers:
The full CPSTF Finding and Rationale Statement and supporting documents for Diabetes Management: Interventions Engaging Community Health Workers are available in The Community Guide Collection on CDC Stacks.
Intervention
Interventions engaging community health workers for diabetes management aim to improve diabetes care and self-management behaviors among patients. Interventions include education, coaching, or social support to improve diabetes testing and monitoring, medication adherence, diet, physical activity, or weight management.
Community health workers deliver services and program content through one-on-one interactions or group sessions. Intervention activities take place in patients’ homes, or community or clinical settings. Community health workers may work alone or as part of an intervention team comprised of clinicians, counselors, or other health professionals.
Community health workers (including promotores de salud, community health representatives, community health advisors, and others) are frontline public health workers who serve as a bridge between underserved communities and healthcare systems. They typically are from or have a unique understanding of the community served.
About The Systematic Review
The CPSTF recommendation is based on evidence from a systematic review of 44 studies (search period through May 2015). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.
Study Characteristics
- Studies were conducted in the United States (39 studies), the United Kingdom (3 studies), and Australia (2 studies)
- Studies were conducted in urban (21 studies), rural (6 studies), or mixed (3 studies) areas
- Included studies evaluated interventions in clinics (13 studies), community centers (6 studies), homes (3 studies), or multiple settings (22 studies)
- Across all 44 studies, more than 70% of participants were female
- Included studies mainly focused on underserved populations and targeted Latinos (16 studies), African-Americans (2 studies), Asians (3 studies), Native Hawaiian or Pacific Islanders (2 studies), and American Indians (2 studies)
- Community health workers engaged participants using a team-based care approach (17 studies), as a member of care delivery team (10 studies), or as the primary implementer (17 studies)
Summary of Results
Overall, included studies showed interventions engaging community health workers improved patients’ glycemic or blood sugar control and reduced their healthcare use.
Glycemic (Blood Sugar) Control
- Mean HbA1c: median decrease of 0.49% (36 studies; median intervention duration: 12 months)
- Proportion at goal A1c (A1c < 7.0%): median increase of 6.6% (7 studies; median duration: 12 months)
- Mean fasting blood glucose: median decrease of 29.5 mg/dL (6 studies; median duration: 12 months)
Healthcare Use
- Studies reported decreases in emergency department visits among patients in intervention groups when compared to those in control groups
- Studies reported changes in hospitalizations among patients in intervention groups when compared to those in control groups
Cardiovascular Disease Risk Factors
- Mean total cholesterol: median decrease of 8.9 mg/dL (12 studies; median duration: 12 months)
- Mean low-density lipoprotein (LDL) cholesterol: median decrease of 6.9 mg/dL (14 studies; median duration: 12 months)
- Mean systolic blood pressure: median decrease of 0.5 mg/dL (22 studies; median duration: 12 months)
- Mean diastolic blood pressure: median decrease of 0.74 mg/dL (18 studies; median duration: 12 months)
Most included studies engaged community health workers to work with underserved groups suggesting these interventions can be effective in improving health and reducing health disparities related to populations at risk for diabetes (36 studies).
Summary of Economic Evidence
Economic evidence indicates that interventions engaging community health workers for diabetes management are cost-effective. All monetary values are reported in 2016 U.S. dollars. The economic review included 13 studies (10 from the United States, 2 from the United Kingdom, and 1 from Australia).
- Median intervention cost per person per year: $585 (13 studies)
- Median change in healthcare cost per person per year: $72 reduction (4 studies)
- Median cost per quality adjusted life year (QALY) gained: $38,276 (5 studies). This estimate falls below $50,000 a benchmark for cost-effectiveness
Applicability
Based on results, the CPSTF finding should be applicable to interventions that engage community health workers in the following settings and populations:
- Adults with type 2 diabetes
- Women and men
- Hispanics, African-Americans, and Asians
- Low-income and low-education populations
- Urban and rural environments
- Clinics, community, and home settings
Evidence Gaps
- How effective are large-scale programs (i.e., >500 participants), programs conducted in rural settings, and programs evaluated over a longer time period?
- What are the challenges or barriers that impact the recruitment and retention of male clients?
- How will changes in Centers for Medicaid (CMS) reimbursement rules affect the use of community health workers and the roles and services they provide?
- How effective are interventions among younger and older adult populations?
- What are the long-term effects on diabetes-related complications and health outcomes?
- How can community health workers be more engaged as outreach, enrollment, and information agents, patient navigators, and community organizers?
- What are the roles and effects of community health workers in a team-based care environment?
Implementation Considerations and Resources
- The 2013 ruling by the Centers for Medicaid and Medicaid Services (CMS) allows states to provide Medicaid reimbursement for preventive services recommended by the U.S. Preventive Services Task Force. Services must be “recommended by a physician or other licensed practitioner,” and they must be delivered by health professionals, which may include community health workers
- States are addressing reimbursement challenges through referral systems that use bidirectional linkages, feedback loops that facilitate communication between referring providers and those delivering services, and educational programs that aim to raise awareness
- Community health workers may be a member of a team or implement interventions alone. Community health workers are typically matched to the populations they serve (i.e., location, race or ethnicity, language or disease status)
- Community health workers most often provide participants with culturally appropriate information and education on diabetes management, help build individual and community capacity, provide informal counseling, coaching, and social support, and facilitate and assist with care coordination and case management
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.