Code: Community Diabetes Education for Uninsured Mexican Americans

Abstract

Low-cost diabetes education programs that target Mexican Americans are essential to reduce the observed health disparities in this population. A culturally appropriate intervention was developed as the centerpiece of the Community Diabetes Education (CoDE) program. This article describes the structure, patient acceptance, and costs of this one-to-one educational model delivered in 7 patient contact hours by a community health worker over 12 months in a community clinic serving the uninsured. A total of 162 patients-predominantly female, Spanish-speaking Mexican American patients with type 2 diabetes of mean duration of 6.5 years-enrolled in the program, and a dropout rate of 22% was observed during the 12-month period. Preliminary analysis indicated that program capacity was 120 patients per month, and the annual direct medical expenditure per CoDE participant was $461. The hemoglobin A(1c) was significantly reduced in patients who participated in the program for 12 months. Sustainable, low-cost, community-based programs like CoDE and long-term patient participation will help reduce the burden of diabetes in the underserved Hispanic population.

Effectiveness of a Community Health Worker as Sole Diabetes Educator: Comparison of CoDE with Similar Culturally Appropriate Interventions

“…11,12 The CoDE program community health worker had a substantial patient capacity of 120 patients per month, which was not exceeded during the feasibility study period. 17 The patient attrition rate of 22% was consistent with rates observed by other investigators. 15 The results of our feasibility study suggested that patient participation in the CoDE program was influenced by continued patient contact with the community health worker.…”

“…Educational and therapeutic guidelines for the three initial educational sessions and the subsequent quarterly educational and assessment components have been described in detail elsewhere. 17 The bilingual community health worker was responsible for delivery of the entire intervention, documentation of all activities within the medical records, and direct, real-time communication with the clinic physicians to address acute medical issues. Health indicators, including a point-of-care HbA1c at baseline and quarterly using a Bayer DCA 20001 Analyzer®, blood pressure measurements with a digital sphygmomanometer, height measurements with a stadiometer, weight measurements with a digital scale, and hand calculations of body mass index (BMI) using the standard formula (kg/m 2 ) were performed by the community health worker during each patient encounter.…”

“…[6][7][8] Culturally appropriate educational and management strategies to address the specific needs of underserved Hispanic populations have been developed and implemented in multiple locations in the United States. [9][10][11][12][13][14][15][16][17] Favorable effects of these programs (which typically employed registered nurses, certified diabetes educators [CDEs] or dietitians as primary patient educators) on glycemic control and other health parameters have been reported. [9][10][11][12]14,16 The limited availability of CDEs in general, and bilingual or bicultural CDEs in particular, prompted many culturally appropriate diabetes education interventions to use promotoras, community health workers, and peer patient educators to handle group educational and skill reinforcement sessions as adjuncts to the primary educators.…”

“…17 CoDE was designed to be an abbreviated, low-cost, one-to-one educational intervention directly integrated into an existing urban community clinic. The clinic structure included three full-time family practice physicians, one of whom was fluent in Spanish, a Class D pharmacy, and a support staff of bilingual medical assistants.…”

“…16 Project Dulce, Border Health ¡Si!, and CoDE were the only programs to report a direct connection between the primary care physician and the educational strategy. 11,14,17 However, the Project Dulce nurse case manager had the expertise and authority to make medication changes 11 while the CoDE community health worker did not have such responsibilities. 17 The CoDE program physicians played a direct role in disease management, while disease management appeared to be taking place primarily within the NCM component of Project Dulce, with the physicians taking a more passive role in approving NCM recommendations.…”