Community Outreach for Navajo People Living with Diabetes: Who Benefits Most?

INTRODUCTION: The Community Outreach and Patient Empowerment (COPE) intervention provides integrated outreach through community health representatives (CHRs) to people living with diabetes in Navajo Nation. The aim of this study was to identify groups for whom the intervention had the greatest effect on glycated hemoglobin A1c (HbA1c). METHODS: We analyzed de-identified data extracted from routine health records dated from December 1, 2010, through August 31, 2014, to compare net change in HbA1c among COPE patients and non-COPE patients. We used linear mixed models to assess whether the intervention was modified by age, sex, preferred language, having a primary care provider, baseline HbA1c, or having a mental health condition. RESULTS: Age, having a primary care provider, and baseline HbA1c significantly modified HbA1c levels. Among patients aged 64 or younger, COPE participation was associated with a net decrease in HbA1c of 0.77%; among patients aged 65 or older, the net decrease was 0.49% (P = .03). COPE participation was associated with a steeper decrease in HbA1c among patients without a primary care physician (net decrease, 0.99%) than among patients with a primary care provider (net decrease, 0.57%) (P = .03). COPE patients with a baseline HbA1c >9% had a net decrease of 0.70%, while those with a baseline HbA1c ≤9% had a net decrease of 0.34% (P = .01). We found no significant differences based on sex, preferred language, or having a mental health condition. CONCLUSION: Findings suggest that the COPE intervention was robust and equitable, benefiting all groups living with diabetes in Navajo Nation, but conferring the greatest benefit on the most vulnerable.

Community-clinic linkages: qualitative provider perspectives on partnering with community health representatives in Navajo Nation.

OBJECTIVE: To understand providers' opinions about the Community Outreach and Patient Empowerment (COPE) Project designed to strengthen Navajo Community Health Representative (CHR) outreach to individuals living with diabetes. DESIGN: This was a qualitative study nested within a larger evaluation of a programme intervention. SETTING: The study took place in Navajo Nation and evaluated a programme initiative designed to strengthen collaboration between CHRs and clinic-based healthcare providers and provide structured outreach to individuals living with diabetes in Navajo Nation. The CHR Programme is a formal community health worker programme that exists in most tribal healthcare systems across the USA. PARTICIPANTS: Healthcare providers involved in the programme took part in one-on-one interviews. ANALYSIS: We used thematic analysis for this study. A team of three study staff used open-coding to create a codebook. Coded material were summarised and patterns were identified and tied into a narrative using concept mapping. The study design and instrument construction were guided by a Community Health Advisory Panel. RESULTS: A total of 13 interviews were completed. Providers acknowledged CHRs as an asset to the clinical team and were enthusiastic about the COPE coaching materials, mentioning they provided a consistent message to CHRs and the community. Providers that led COPE trainings with CHRs valued the face-to-face time and opportunity to build relationships. Providers (n=4) supported CHRs' access to electronic health record to record patient visits and streamline referrals. Among their requests were having designated personnel to manage referrals with CHRs and a formal system to record modules CHRs have completed. CONCLUSION: Providers participating in COPE activities valued the work of CHRs and endorsed further strengthening relationships and communication with CHRs. Healthcare programmes should consider systems changes to integrate community health workers into clinic-based teams. TRIAL REGISTRATION NUMBER: NCT03326206; Results.

Qualitative evaluation of a community health representative program on patient experiences in Navajo Nation.

BACKGROUND: Community Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturally-appropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation. METHODS: Seven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes. RESULTS: Clients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management. CONCLUSION: The COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients' families may foster these relationships and improve health outcomes. TRIAL REGISTRATION: clinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).

Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.

BACKGROUND: We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits. METHODS: We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models. RESULTS: Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group. CONCLUSION: Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population. TRIAL REGISTRATION: Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.

Identifying risk factors for 30-day readmission events among American Indian patients with diabetes in the Four Corners region of the southwest from 2009 to 2016.

OBJECTIVE: The objective of this study was to identify risk factors for 30-day readmission events for American Indian patients with diabetes in the southwest. RESEARCH DESIGN AND METHODS: Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using logistic regression analyses. RESULTS: Of 2,660 patients, 394 (14.8%) patients had at least one readmission within 30 days of discharge. Older age (OR (95% CI) = 1.26, (1.17, 1.36)), longer length of stay (OR (95% CI) = 1.01, (1.0001, 1.0342)), and a history of substance use disorder (OR (95% CI) = 1.80, (1.25, 2.60)) were risk factors for 30-day readmission. An American Indian language preference was protective against readmission. CONCLUSIONS: Readmission events are complex and may reflect broad and interwoven disparities in community systems. Future research should work to support community-defined interventions to address both in hospital and external factors that impact risk factors for readmission.

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.

OBJECTIVES: To evaluate the role of primary care healthcare delivery on survival for American Indian patients with diabetes in the southwest United States. METHODS: Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using a log-rank test and Cox Proportional Hazards analyses. RESULTS: Of the 2661 patients included in analysis, 286 patients died during the study period. Having visited a primary care provider in the year prior to first admission of the study period was protective against all-cause mortality in unadjusted analysis (HR (95% CI)=0.47 (0.31, 0.73)), and after adjustment. The log-rank test indicated there is a significant difference in overall survival by primary care engagement history prior to admission (p<0.001). The median survival time for patients who had seen a primary care provider was 2322days versus 2158days for those who had not seen a primary care provider. CONCLUSIONS: Compared with those who did not see a primary care provider in the year prior to admission, having seen a primary care provider was associated with improved survival after admission.

Strengthening the role of Community Health Representatives in the Navajo Nation.

BACKGROUND: Strengthening Community Health Worker systems has been recognized to improve access to chronic disease prevention and management efforts in low-resource communities. The Community Outreach and Patient Empowerment (COPE) Program is a Native non-profit organization with formal partnerships with both the Navajo Nation Community Health Representative (CHR) Program and the clinical facilities serving the Navajo Nation. COPE works to better integrate CHRs into the local health care system through training, strengthening care coordination, and a standardized culturally appropriate suite of health promotion materials for CHRs to deliver to high-risk individuals in their homes. METHODS: The objective of this mixed methods, cross sectional evaluation of a longitudinal cohort study was to explore how the COPE Program has effected CHR teams over the past 6 years. COPE staff surveyed CHRs in concurrent years (2014 and 2015) about their perceptions of and experience working with COPE, including potential effects COPE may have had on communication among patients, CHRs, and hospital-based providers. COPE staff also conducted focus groups with all eight Navajo Nation CHR teams. RESULTS: CHRs and other stakeholders who viewed our results agree that COPE has improved clinic-community linkages, primarily through strengthened collaborations between Public Health Nurses and CHRs, and access to the Electronic Health Records. CHRs perceived that COPE's programmatic support has strengthened their validity and reputation with providers and clients, and has enhanced their ability to positively effect health outcomes among their clients. CHRs report an improved ability to deliver health coaching to their clients. Survey results show that 80. 2% of CHRs feel strongly positive that COPE trainings are useful, while 44.6% of CHRs felt that communication and teamwork had improved because of COPE. CONCLUSIONS: These findings suggest that CHRs have experienced positive benefits from COPE through training. COPE may provide a useful programmatic model on how best to support other Community Health Workers through strengthening clinic-community linkages, standardizing competencies and training support, and structuring home-based interventions for high-risk individuals.

Cultural elements underlying the community health representative - client relationship on Navajo Nation.

BACKGROUND: Navajo Nation Community Health Representatives (CHR) are trained community health workers (CHWs) who provide crucial services for patients and families. The success of the CHRs' interventions depends on the interactions between the CHRs and their clients. This research investigates the culturally specific factors that build and sustain the CHR-client interaction. METHODS: In-depth interviews were conducted with 16 CHRs on Navajo Nation. Interviews were transcribed and coded according to relevant themes. Code summaries were organized into a narrative using grounded theory techniques. RESULTS: The analysis revealed four findings critical to the development of a CHR-client relationship. Trust is essential to this relationship and provides a basis for providing quality services to the client. The ability to build and maintain trust is defined by tradition and culture. CHRs must be respectful of the diverse traditional and social practices. Lastly, the passing of clients brings together the CHR, the client's family, and the community. CONCLUSION: Understanding the cultural elements of the CHR-client relationship will inform the work of community partners, clinical providers, and other indigenous communities working to strengthen CHR programs and obtain positive health outcomes among marginalized communities.