Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial

Abstract

PURPOSE Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes. METHODWe undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA 1C ) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA 1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA 1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA 1C level of 1.0% or more and proportion of patients with an HbA 1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.RESULTS At 6 months, HbA 1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA 1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).CONCLUSIONS Peer health coaching signifi cantly improved diabetes control in this group of low-income primary care patients. Ann Fam Med 2013;11:137-144. doi:10.1370/afm.1443. INTRODUCTIONP rimary care faces serious challenges in the face of the growing demand for diabetes care. Primary care physicians are in short supply and need more time to care for patients with highly complex conditions whose costs are destabilizing US health care.1 Current numbers of nurse practitioners and physician assistants are not suffi cient to provide access to the increasing demand for primary care.1,2 Registered nurses and pharmacists, who are capable of managing a large proportion of patients with diabetes, are too costly for many primary care practices. The time of medical assistants is often consumed by managing patient fl ow and assisting clinicians to get through the day. 3 In sum, many primary care practices have no one available to provide the time-consuming counseling and teaching of self-management skills that have been shown to improve diabetes outcomes. 4 To address this need, several models have been developed to provide support for patient self-management from lay workers with minimal 138 PEER HE A LT H COACHING A ND G LYC EMIC CON T ROLtraining, including community health workers, lay peer educators, and peer coaches. Community health workers are from the community of the patients they assist but do not necessarily have the same disease as the patient. ...

Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics

“…Others can contribute to DSME and provide support with appropriate training and supervision. Trained community health workers, practice-based care managers, peers, and other support persons (e.g., family members, social workers, and mental health counselors) have a role in helping to sustain the benefits gained from DSME (37)(38)(39)(40)(41). Such staff/resources can be especially helpful in areas with diverse populations and serve as cultural navigators in health care systems and as liaisons to the community.…”

Peer Coaching to Improve Diabetes Self-Management: Which Patients Benefit Most?

“…12,21 Patients receiving care at one of six public clinics in San Francisco were eligible for randomization if they spoke English or Spanish, had a hemoglobin A1c≥8.0 % within the 6 months prior to enrollment, and were not identified as inappropriate for the intervention by their primary care provider.…”

“…6,7 Peer health coaches have been successful at enhancing self-management and in lowering hemoglobin A1c in diabetic patients. [8][9][10][11][12] Patients' success at controlling their diabetes is not uniform. Both individuals from low socioeconomic status and from non-white racial/ethnic groups have poorer control 13 and higher diabetes related morbidity.…”

“…However, it is unknown whether peer health coaches are equally effective for all patients with poorly controlled diabetes, or whether coaching interventions could be more effective if targeted to subgroups. We conducted a secondary analysis of a randomized control trial that found a significant improvement in diabetes control in patients receiving peer coaching compared to usual care, 12 to investigate whether the effect of a peer health coaching intervention was modified by patient characteristics associated with glycemic control.…”

Appointment “no-shows” are an independent predictor of subsequent quality of care and resource utilization outcomes

“…In a setting of increasing emphasis on population health management, our findings have policy and care delivery implications, given the importance of identifying patients at increased risk of adverse clinical outcomes for targeted intervention. The disparities in rates of cancer screening and 15,16 could target patients with chronic diseases and high NSPF to improve disease control. Patients in the high NSPF group had 40-50 % increased rates of ED utilization and hospitalization in the subsequent 3 years, suggesting that high NSPF may serve as an important predictor for future acute care utilization.…”