Peer Care in Diabetes Support and Control:
Meeting of the Diabetes Mellitus Interagency Coordinating Committee
July 18, 2012 Web Conference
Peer Support in Diabetes Management: Approaches, Evidence, and Dissemination—Edwin B. Fisher, Ph.D., Professor, Department of Health Behavior, Gillings School of Global Public Health, UNC-Chapel Hill; Global Director, Peers for Progress, American Academy of Family Physicians Foundation
Dr. Fisher began his presentation by noting the fundamental role of social connections and support as it relates to human health and well-being. He noted that people are more effective and happier when they have someone to talk to and who care about them. This is underscored by data showing that all-cause mortality associated with social isolation is comparable to that attributable to cigarette smoking.
Diabetes is a disease in which the vast majority of management is done by the patient without direct support from a health care professional. Research has shown that, while diabetes self-management education is important for helping patients manage the disease, improvements in outcomes tend to diminish after about 6 months. As per guidelines of the American Diabetes Association and the American Association of Diabetes Educators, most patients also need ongoing support to implement and sustain the behaviors required to manage their disease. Peers are a potential source of such support.
Peer supporters are not professionals, and often have the same health problem as the person they are helping. The peer supporters share perspectives and experiences, can teach patients how to implement basic self-management plans, and have time to dedicate to helping the patient. Patients tend to believe the peer supporters because they think of the peer as someone “like me.” Dr. Fisher described a number of studies that provided scientific evidence of the benefits of peer support. In a meta-analysis of publications related to peer support published from 2000-2011, 55 of 66 Studies (83.3%) showed benefits of peer support. Further, in a review of 14 studies of peer support in diabetes (through July, 2012) conducted for this presentation, mean HbA1c declined from 8.63% prior to peer support intervention to 7.77% after the intervention (p = 0.001).
Dr. Fisher next discussed promotion and dissemination approaches through Peers for Progress, an organization that promotes peer support as a key part of health, health care, and prevention around the world. A challenge to global promotion of peer support is that because of cultural differences it is not possible to develop a single protocol that would work around the world. Nevertheless, representatives of 20 countries at a World Health Organization consultation in November 2007 concluded that there are “key functions” of peer support that are global, but that how they are addressed needs to be worked out within each setting. As such, Peers for Progress has defined peer support according to four key functions: (1) assistance, consultation in applying management plans in daily life; (2) social and emotional support; (3) linkage to clinical care; and (4) ongoing support, extended over time.
Dr. Fisher noted that evaluations of peer support programs often focus on their efficacy and effectiveness, but should also consider the implementation process, including feasibility, reach/engagement, sustainability, and adoption. Dr. Fisher noted ways the Patient Protection and Affordable Care Act may affect peer support: the Act includes community health workers (CHWs) in a number of provisions and planned initiatives, such as the Chronic Health Home; Medicaid expansion will include populations and problems for which peer support is especially well suited; and the Act’s emphasis on the Patient-Centered Medical Home and related models will provide an organizational base for peer support interventions.
Dr. Fisher discussed answers to some frequently asked questions about peer support:
Who is a peer? A peer need not have the disease for which they are to provide support but should have close experience with diabetes or other chronic diseases. (Type 1 diabetes may be an exception in that those with this disease may feel no one who has not “walked in my shoes” can understand the challenges they face and provide pertinent support.) The peer may be a volunteer, but payment may be justified if extensive services are required (such as attendance at regularly scheduled clinic times.)
How do you address quality control/misinformation? It is important to provide solid training and to carefully select for peers willing to be part of a team, as opposed to people wanting to be the source of all knowledge and help. Thus, the peers must know their role is to provide support and assistance, not clinical expertise. Also, peers themselves require back-up, support, and monitoring; if this is provided, peers selected for a high level of responsibility will use that back-up resource rather than providing reckless attempts to help people in duress.
What characteristics make a good peer supporter? Qualities include: having time available to dedicate to peer support; liking to talk to others; emotional sensitivity; being broad-minded so as not to see diabetes or people’s problems as simple; being able to learn and teach basic diabetes management; and willingness to use back-up support from professionals.
How do you train peer supporters? It appears best to organize training around the curriculum or protocol that peers will implement, focusing on the concrete services of the protocol. As they gain experience, peers will then be able to benefit from “in service” training addressing more complex skills such as motivational interviewing, active listening, etc.
Finally, Dr. Fisher outlined some factors for a successful peer support program: (1) “keep it simple,” because peer support is supposed to come from “people like me;” (2) avoid too many details of training, since keys for success are knowing, listening, and being available; (3) provide ongoing support and information for peer supporters; (4) have a back-up system in place; and (5) provide an organizational structure to support the peer support program, whether in the community or in a clinical setting.
Peer Support in Diabetes Management: Some Successful Models and Future Directions—Michele Heisler, M.D., M.P.A., Associate Professor, Internal Medicine, Associate Professor, Health Behavior & Health Education, University of Michigan
Dr. Heisler presented on evaluated models of peer support in diabetes, with an emphasis on diabetes self-management. She noted that patient self-management is central to diabetes outcomes, but can be difficult for many patients. Data show care management programs that are effective in improving self-management and diabetes risk factor control require significant human resources and are expensive. Also, research has shown that benefits from highly effective short-term programs are not sustained without follow-up support. Therefore, a key challenge is how to sustain gains from training. Thus, there is a need for flexible, sustainable, low-cost programs that are tailored to the needs of individual patients, linked to outpatient care processes, and complement (rather than substitute for) formal health care.
Dr. Heisler underlined two take-away lessons learned from randomized controlled trials (RCTs) on different peer support models. First, face-to-face peer-led group visits and training sessions can improve outcomes, but many patients do not attend such visits. Indeed, even in effective programs, up to one-third of patients did not attend any sessions. Second, effective models require proactive outreach, and are linked to structured training and support programs.
Dr. Heisler next presented data on three different types of peer support models: CHW, peer mentor, and reciprocal peer support. She noted that the three models have several common features, in that the peer training focuses on evidence-based behavioral support approaches, they have strong oversight from and linking to health care providers, and they provide follow-up training to the peers.
The first model that Dr. Heisler discussed was CHWs. CHWs are peers in that they share the same neighborhood and cultural and linguistic background as patients, and sometimes also share the same chronic condition. Several RCTs have demonstrated effectiveness of CHW-led diabetes self-management programs. Dr. Heisler described a trial she conducted that compared a CHW program with usual care among 183 African American and Latino adults with diabetes. After 6 months, average A1C levels in the intervention group reduced from 8.7 to 7.8 percent, a statistically significant improvement compared to the more modest change of 8.6 to 8.3 percent observed in the control group. There was also a reduction in measures of diabetes-specific distress in the intervention group, but not in the control group. Thus, the short-term CHW intervention was found to be effective. However, since CHWs are salaried workers, there is a need to examine the cost-effectiveness of such an approach; and effective, sustainable strategies may be needed to maintain such improvements. The next model Dr. Heisler presented was peer mentoring, in which patients provide support to other patients. She reviewed data from a trial testing the relative effectiveness of peer mentoring, financial incentives (lump sum reward for improvements after 6 months), and usual care in improving glucose control among low-income African Americans in the Veterans Administration (VA). After 6 months, A1C levels were unchanged in the usual-care control group, decreased by 1 percent in the peer mentor group, and decreased by 0.4 percent in the financial incentives group. Thus, peer support achieved greater improvements than financial incentives in this population. A larger, longer trial outside of the VA is under way.
The third model that Dr. Heisler presented was reciprocal peer support, in which participants both give and receive support. Because reciprocal peer support had never been rigorously tested in chronic disease care, Dr. Heisler developed and conducted an RCT to test the model. The trial enrolled 244 veterans with diabetes to compare reciprocal peer support with usual nurse care management. Results showed the reciprocal-peer approach yielded statistically and clinically significant improvements in A1C, insulin starts, and diabetes social support. Also, from a health care staff perspective, delivering the intervention was less time intensive than other tested programs that achieved similar or smaller improvements in glycemic control. Based on the results, Dr. Heisler concluded that reciprocal peer support can be an effective and efficient way to help people with diabetes.
In the last section of her presentation, Dr. Heisler discussed two variations on peer support currently being evaluated: (1) combining different kinds of peer support models to sustain gains, and (2) the development of web-based, interactive, tailored tools for peers. For the first intervention, Dr. Heisler is building on the CHW-led trial that showed benefits after a 6-month intervention (described above). She is now evaluating the effectiveness of a 12-month program led by diabetes patients who had themselves successfully completed a CHW-led diabetes self-management program, and were then trained to provide peer support to other participants. The goal is that, just as CHWs play complementary roles to health care professionals, trained peer mentors can play complementary roles to CHWs. For the second intervention, Dr. Heisler discussed web-based, tailored tools that have been developed for peers. For example, she noted the promise of E-technology to facilitate peer supporter discussions with patients.
Community Health Workers: Critical Community Connections—Kris Ernst, R.D., C.D.E., Program Consultant, Division of Diabetes Translation, Centers for Disease Control and Prevention (CDC)
Ms. Ernst’s presentation focused on CHWs. Over the past 10 years, CHW has become an umbrella term that covers over 60 different terms that define functional job and volunteer titles. The American Public Health Association defines CHW as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” This relationship enables the CHW to serve as a liaison, link, or intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
Ms. Ernst noted several reasons why it is beneficial to engage CHWs in diabetes or chronic disease prevention and control. In particular, CHWs provide a return on investment of about $3 for each $1 invested, saving about $2,000/patient/year. Further, the National Community Health Advisor Study (1998) identified the following seven core roles for CHWs that are still used today:
- Bridging cultural mediation between communities and the health and social services system;
- Providing culturally appropriate health education and information;
- Assuring that people get the services they need;
- Providing informal counseling and social support;
- Advocating for individual and community needs;
- Providing direct services; and
- Building individual and community capacity.
Ms. Ernst discussed some challenges with the CHW model, including the issue of sustainable funding, as grants are often short-term and programs may not be able to pay CHWs or give them full-time, long-term work. In addition, CHW services are usually not reimbursable by health insurers.
Ms. Ernst provided information on CDC programs related to CHWs. For example, the “Road to Health Toolkit” was developed by the National Diabetes Education Program (a partnership of NIDDK and CDC) as a resource for CHWs—as well as nurses, health educators, and dietitians—serving African American and Hispanic/Latino communities. The Toolkit is focused on primary prevention of type 2 diabetes, based on results from the NIDDK-led Diabetes Prevention Program (DPP) clinical trial, and was developed to meet a need for low health literacy resources for at-risk individuals. Another example is the CDC’s Native Diabetes Wellness Program, which addresses the health disparities related to diabetes in Indian Country. The Wellness Program developed the Eagle Books series. The books were written by a Community Health Representative who was concerned about how diabetes was affecting her community.
Ms. Ernst next presented information on the CDC’s National Diabetes Prevention Program, which trains lifestyle coaches to deliver a lifestyle intervention to people with prediabetes. The Program was launched in partnership with the Y (formerly YMCAs) and UnitedHealth Group. It is based on results from the DPP, as well as an NIDDK-supported pilot study that utilized local Ys for delivering a group-based adaptation of the DPP lifestyle intervention. To date, 754 classes have started and 6,000 participants have enrolled; average weight loss is 5.1 percent for people attending at least nine sessions. Finally, Ms. Ernst reported that the CDC’s Division of Diabetes Translation is in the process of developing “A Program Guide for Public Health: Sustaining the Work of Community Health Workers for the Prevention and Control of Chronic Diseases.”
For general information about the history, goals, membership, and activities of the DMICC, please see the DMICC web page or the publication, “DMICC: Coordinating the Federal Investment in Diabetes Programs To Improve the Health of Americans.” (PDF, 2,206 kb)
Ms. Ernst, CDC
Dr. Fisher, University of North Carolina
Dr. Heisler, University of Michigan
DMICC Members Participating
Dr. Fradkin, NIDDK, Chair
Dr. Garfield, NIDDK, Executive Secretary
Dr. Alekel, NCCAM
Dr. Avilès-Santa, NHLBI
Dr. Bourcier, NIAID
Dr. Bullock, IHS
Dr. Calvo, HRSA
Dr. Frant, NLM
Dr. Graves, CSR
Dr. Khalsa, NIDA
Dr. Koller (for Dr. Roman), CMS
Dr. Krosnick (for Dr. Conroy), NIBIB
Dr. Li, NHGRI
Dr. Saydah (for Dr. Albright), CDC
DMICC Members Not Attending
Dr. Atkinson, NIDCR
Dr. Bartman, AHRQ
Dr. Chavez, NIMH
Dr. Dankwa-Mullan, NIMHD
Dr. Dutta, NIA
Dr. Eberhardt, CDC
Dr. Gao, NIAAA
Dr. Graham, HHS OMH
Dr. Grave, NICHD
Dr. Gwinn, NINDS
Dr. Heindel, NIEHS
Dr. Krasnewich, NIGMS
Dr. Kugler, DOD
Dr. Parks, FDA
Dr. Penn, NINDS
Dr. Peyman, NIAID
Dr. Pogach, VHA
Dr. Post, USDA
Dr. Rosenblum, NCATS
Dr. Shen, NEI
Dr. Siegel, NLM
Dr. Srinivasan, HHS
Dr. Valdez, IHS
Dr. Wasserman, NINR
Dr. Wong, NIDCD
Dr. Wu, HRSA
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