Community Health Worker Home Visits for High-Risk Diabetes Patients

By Hannah Lambalot | Categories: | Comments Off on Community Health Worker Home Visits for High-Risk Diabetes Patients

Harris Health System, in Houston, serves a largely low-income and uninsured or underinsured patient population, of which nearly 90 percent are people of color. These communities experience a disproportionate prevalence of diabetes, and Type 2 diabetes ranks among the most prevalent and costly outpatient diagnoses.

Spurred in part by a Medicaid Section 1115 waiver, the health system developed a diabetes registry that identified nearly 40,000 diagnosed patients, including about one-third who had uncontrolled diabetes with HbA1c levels greater than 9. In 2017, Harris Health then designed a community health worker (CHW) home visit pilot program that uses a hub-and-spoke, community-focused model to work with disengaged patients with diabetes. Through the program, CHWs capture a comprehensive picture of patients’ health-related social needs, diabetes knowledge, and self-management behaviors. The four-month program extends the health system’s reach outside its walls to better understand barriers to good health and offer point-of-care navigation. CHWs launch a care plan that can include establishing eligibility for charity care, making appointments with interdisciplinary teams, applying for rental assistance, education on public transportation, and more.

Since its inception, the program has grown to 14 clinics. In 2020, COVID-19 created new barriers for patient self-management of diabetes and the health system responded by shifting the program to include virtual and telehealth care; this transition coincides with a 130 percent increase in the number of program graduates. Before the start of the pandemic, 181 program participants reported an average decrease of 2.2 percentage points in HbA1c levels and increased knowledge of their condition and appropriate treatment. The program sustained these outcomes amid the pandemic, with 417 patients completing the program from November 2020 to October 2021.