Evaluating Home-Based Health Coaching from Community Health Representatives for Navajo Adults with Type 2 Diabetes

This project has results

Abstracts

Public Abstract

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Type 2 diabetes causes a person’s blood sugar level to rise higher than normal. Good health care can prevent diabetes from damaging organs such as the kidneys and heart. But many adults living on the Navajo reservation can’t get the care they need.

Since 2010, the Indian Health Service and the Navajo Nation Department of Health have run an at-home diabetes education program for the Navajo Nation. Community health representatives, or CHRs, carry out the program and are part of the clinic healthcare team. They are from the Navajo community and speak the Navajo language. Doctors and CHRs invite adults with high risks related to diabetes to take part in the program. CHRs visit those in the program at home once or twice a month for up to one year. During home visits, CHRs check health, share information, and give support. People choose topics they want to learn about and decide on healthy changes they want to make. The CHRs leave notes in health records to let doctors at the clinics know about people’s needs.

In this study, the research team wanted to learn if the program improved health and healthcare use. The team compared health records of people in the program with people who weren’t in the program.

What were the results?

Blood sugar levels. People in the program lowered their blood sugar levels more than people who weren’t in the program.

Risks related to diabetes. People in the program reduced some risks related to diabetes, such as high cholesterol, more than people who weren’t in the program. For other risks, such as having high blood pressure or being overweight, the two groups didn’t show differences likely to affect health.

Use of health care. People in the program improved their use of some health services. They had more visits to primary care doctors, counselors, and pharmacies than people who weren’t in the program. The two groups didn’t differ in the number of visits to emergency rooms or hospital stays.

Who was in the study?

The study looked at health records from 173 Navajo adults with type 2 diabetes in the program and 2,885 Navajo adults with type 2 diabetes who weren’t in the program. Of those in the program, 77 percent were age 56 or older, 62 percent were women, and 58 percent preferred to use an indigenous language. Of those not in the program, 77 percent were age 56 or older, 69 percent were women, and 41 percent preferred to use an indigenous language. All received health care from Navajo Area Indian Health Service clinics.

What did the research team do?

Using health records of the Navajo Area Indian Health Service, the research team identified people in the program and people with similar traits, such as age, who weren’t in the program. The team compared blood sugar levels, risks related to diabetes, and healthcare use at the start of the study and again two years later.

Navajo adults who had been in the program, their relatives, tribal leaders, CHRs, doctors, and nurses helped design and carry out the study.

What were the limits of the study?

People who took part in the program chose to do so. They may differ from people who didn’t take part in the program. Also, health records were missing some information.

Future research could test the program in other communities with few healthcare resources or in people with other health problems.

How can people use the results?

Clinics could use these results when planning how best to provide care for people with diabetes.

Professional Abstract

Objective

To evaluate the impact of Community Outreach and Patient Empowerment (COPE), a program that provides home-based health coaching from community health representatives (CHRs), on indicators of diabetes control and healthcare utilization among Navajo adults with type 2 diabetes

Study Design

Design Elements Description
Design Observational: cohort study
Population Health records from 3,058 Navajo adults with type 2 diabetes receiving care at 6 NAIHS units
Interventions/
Comparators
  • COPE, home-based diabetes education delivered by CHRs, plus usual care from NAIHS
  • Usual care from NAIHS
Outcomes

Primary: change in HbA1c

Secondary: LDL, change in systolic blood pressure, BMI, and healthcare utilization
Timeframe 2-year follow-up for primary outcome

This prospective observational study of Navajo adults with type 2 diabetes receiving care from the Navajo Area Indian Health Service (NAIHS) compared outcomes among patients who participated in COPE with those who did not participate. As part of COPE, clinic-based providers and trained Navajo CHRs work together to identify Navajo adults at increased risk of diabetes complications. In addition to community-wide health promotion, CHRs provide individualized care in patients’ homes up to twice per month for at least one year, including

  • Checking patients’ vital signs, coaching patients on diabetes self-management, and helping patients set health goals
  • Supporting medication adherence
  • Helping participants schedule and attend clinic appointments
  • Reporting issues encountered during home visits to clinic-based providers

The program strengthens connections between CHRs and clinic-based providers. At some sites, CHRs can leave notes for clinic-based providers in patients’ electronic health records (EHRs).

Researchers abstracted data from the NAIHS EHR systems to identify the study cohort of 173 patients in COPE. They matched 2,885 patients not in COPE based on age, gender, clinic, HbA1c, and systolic blood pressure. At baseline, 77% of both cohorts were age 56 or older; 62% of the COPE and 69% of non-COPE cohorts were female; and 58% of COPE and 41% of non-COPE cohorts reported an indigenous language as their preferred language. Researchers compared changes over two years on clinical outcomes and healthcare utilization between the two cohorts.

Patients who previously participated in COPE, relatives of patients, tribal leaders, CHRs, clinicians, and administrators helped design and conduct the study.

Results

Compared with patients in the non-COPE cohort, patients in the COPE cohort had

  • Clinically meaningful improvements in HbA1c and low-density lipoprotein (LDL). The baseline HbA1c average was 8.39% among the COPE cohort and 8.23% among the non-COPE cohort. Relative to baseline values, HbA1c decreased by 0.56% among the COPE cohort but increased by 0.07% among the non-COPE cohort (p<0.0001). LDL decreased by an average of 8.04 mg/dL among the COPE cohort and 3.21 mg/dL among the non-COPE cohort (p=0.02).
  • Statistically significant, but not clinically meaningful, increases in systolic blood pressure. Systolic blood pressure increased by 1.43 mmHg among the COPE cohort and increased by 0.28 mmHg among the non-COPE cohort (p=0.004).
  • Statistically significant improvements in utilization of outpatient primary care (p=0.024), counseling and behavioral health services (p=0.013), and pharmacy services (p<0.001).

The two cohorts did not differ significantly in change in body mass index and the number of emergency department visits or hospital stays.

Limitations

Patients self-selected into COPE, which could bias study results. In addition, missing EHR data limited matching of patients in and not in COPE and reduced the sizes of cohorts analyzed.

Conclusions and Relevance

Home-based coaching and greater coordination between clinic-based providers and CHRs led to improvement in several indicators of diabetes control and healthcare utilization among Navajo adults in this study. This approach may be promising for improving type 2 diabetes self-management among adults living in other medically underserved areas.

Future Research Needs

Future research could examine the impact of COPE among individuals living with other chronic health problems and in other communities.

Journal Articles

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PLoS One

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Primary Care Diabetes

Primary care and survival among American Indian patients with diabetes in the Southwest United States: Evaluation of a cohort study at Gallup Indian Medical Center, 2009-2016

BMC Public Health

Strengthening the role of Community Health Representatives in the navajo nation

BMC Health Services Research

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More on this Project  

This project's final research report is expected to be available by August 2019.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:

  • Reviewers expressed concern about identifying themes from the very small number of patients, seven, who participated in the portion of the study involving qualitative interviews. The researchers said the small number reflected the number of patients who had completed both baseline and follow-up surveys but that survey responses available from a somewhat larger set of patients, followed many of the same themes.
  • Reviewers wondered why a relatively small number of patients received the intervention given the much larger pool considered. Reviewers asked whether the selection process may have introduced bias, perhaps magnifying the effects of the intervention. The researchers said the number of community health representatives available limited the study’s size. The researchers acknowledged that since patients volunteered to participate, and the study did not collect systematic data on the reasons why other patients did not participate, the findings might not be generalizable.

Conflict of Interest Disclosures

View the COI disclosure form.

Project Details

Principal Investigator
Sonya Shin, MD, MPH
Project Status
Completed; PCORI Public and Professional Abstracts Posted
Project Title
Evaluating the Navajo Community Outreach and Patient Empowerment (COPE) Program
Board Approval Date
September 2013
Project End Date
December 2018
Organization
Brigham and Women's Hospital
Year Awarded
2013
State
Massachusetts
Year Completed
2018
Project Type
Research Project
Health Conditions 
Multiple/Comorbid Chronic Conditions
Cardiovascular Diseases
Cardiovascular Diseases - Other
Hypertension
Nutritional and Metabolic Disorders
Diabetes
Obesity
Nutritional and Metabolic Disorders - Other
Funding Announcement
Addressing Disparities
Project Budget
$1,863,965
Study Registration Information
HSRP20143385
NCT03326206
Page Last Updated: 
July 1, 2019