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Diabetes Management: Interventions Engaging Community Health Workers

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What the CPSTF Found

About The Systematic Review

The CPSTF recommendation is based on evidence from a systematic review of 44 studies (search period through May 2015).

The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.

Summary of Results

More details about study results are available in the CPSTF Finding and Rationale Statement.

Interventions that engage community health workers for diabetes management use one or more of the following models of care (HRSA 2007).

  • Screening and health education. Community health workers deliver individual or group education on diabetes self-management, provide adherence support for medications, and monitor patients’ blood pressure as recommended by the American Diabetes Association. For example, community health workers might teach patients how to plan healthy meals to improve glucose levels, or how to use a medication diary to track adherence (38 studies).
  • Outreach, enrollment, and information. Community health workers reach out to individuals and families who are eligible for medical services, help them apply for these services, and provide them with proactive follow-up and monitoring, such as appointment reminders and home visits. They might deliver social support at home, or monitor and follow-up on patients’ weight and blood pressure by phone (14 studies).
  • Member of care delivery team. Community health workers partner with patients and licensed providers, such as physicians and nurses, to improve coordinated care and support for patients. For example, community health workers could coordinate patients’ vision and foot care management (e.g., screening) with nurses to reduce diabetes complications (27 studies, of which 17 met criteria for team-based care).
  • Patient navigation. Community health workers help individuals and families navigate complex medical service systems and processes to increase their access to care. Community health workers could improve patients’ access to insurance or prepare them for healthcare visits (9 studies).
  • Community organizers. Community health workers may facilitate self-directed change and community development by serving as liaisons between communities and healthcare systems. For example, community health workers might serve as liaisons between the community and those implementing an intervention to ensure program materials are culturally appropriate and specific to their community (1 study).

Overall, included studies showed the following:

  • Interventions engaging community health workers improved patients’ glycemic or blood sugar control (HbA1c, proportion at goal A1c [A1c < 7.0%], fasting blood glucose) and reduced their healthcare use.
  • Improvements were seen for self-reported lifestyle changes (i.e. physical activity, nutrition).
  • Results were mixed for cardiovascular disease risk factors and weight-related outcomes.

Glycemic (Blood Sugar) Control

  • Mean HbA1c: median decrease of 0.49% (36 studies; median intervention duration: 12 months)
  • Proportion at goal A1c (A1c < 7.0%): median increase of 6.6% (7 studies; median duration: 12 months)
    • Three additional studies measured the proportion of participants who reached their A1c goal at different cutoffs and showed favorable increases.
  • Mean fasting blood glucose: median decrease of 29.5 mg/dL (6 studies; median duration: 12 months)
  • One study reported a mean decrease of 1.85% in A1c among participants whose baseline A1c was 9% or higher (p<0.001).

Healthcare Use

  • Studies reported decreases in emergency department visits among patients in intervention groups when compared to those in control groups.
    • There was a 26 percentage point decrease in the number of visits (p<0.05; 1 study)
    • The rate of visits was reduced by 44% (95% CI: -67% to -4%; 1 study)
    • There were 0.18 fewer visits (p=0.02; 1 study)
  • Studies reported changes in hospitalizations among patients in intervention groups when compared to those in control groups.
    • The rate of visits was reduced by 5% (95% CI: -45% to 66%; 1 study)
    • There were 0.45 more visits (p=0.02; 1 study)
  • One study reported non-significant improvements or decreases across all outcomes (i.e., outpatient visits, emergency department visits, hospitalizations, hospital days).

Cardiovascular Disease Risk Factors

  • Mean total cholesterol: median decrease of 8.9 mg/dL (12 studies; median duration: 12 months)
  • Mean low-density lipoprotein (LDL) cholesterol: median decrease of 6.9 mg/dL (14 studies; median duration: 12 months)
  • Mean high-density lipoprotein (HDL) cholesterol: median increase of 1.1 mg/dL (9 studies; median duration: 18 months)
  • Mean triglycerides: median decrease of 12.6 mg/dL (9 studies; median duration: 18 months)
  • Mean systolic blood pressure: median decrease of 0.5 mg/dL (22 studies; median duration: 12 months)
  • Mean diastolic blood pressure: median decrease of 0.74 mg/dL (18 studies; median duration: 12 months)

Weight-Related Outcomes

  • Mean weight: median increase of 1.1 lbs. (10 studies; median duration: 15 months)
  • Mean body mass index (BMI): median decrease of 0.2 kg/m2 (17 studies; median duration: 6 months)

Health Behavior Outcomes

  • Physical activity: significant improvements (median duration: 3 months; 3 studies), non-significant improvements (median duration: 6 months; 7 studies), no change (median duration: 9 months; 4 studies), and a decrease in physical activity (1 study)
  • Nutrition: significant improvements (2 studies), non-significant improvements (median duration: 6 months; 8 studies), and no change (2 studies).

Most included studies engaged community health workers to work with underserved groups suggesting these interventions can be effective in improving health and reducing health disparities related to populations at risk for diabetes (36 studies).

Additional Findings

In 17 of the included studies, community health workers were used in team-based care.

  • Patients’ glycemic control was the same when community health workers implemented interventions alone or were engaged in team-based care (-0.6% A1c for both)
  • Greater changes in blood pressure were seen among patients when community health workers were used in team-based care.
    • Interventions that engaged community health workers in team-based care decreased systolic blood pressure by 2.6 mmHg and diastolic blood pressure by 3.0 mmHg (10 studies)
    • Interventions that used community health workers alone increased systolic blood pressure by 2.2 mmHg and diastolic blood pressure by 1.4 mmHg (12 studies)

    Three studies evaluated the incremental effectiveness of adding community health workers to diabetes management interventions and reported improvements in glycemic control (1 study) and blood pressure (2 studies).

Summary of Economic Evidence

More details about study results are available in the CPSTF Finding and Rationale Statement.

Economic evidence indicates that interventions engaging community health workers for diabetes management are cost-effective. All monetary values are reported in 2016 U.S. dollars.

The economic review included 13 studies (10 from the United States, 2 from the United Kingdom, and 1 from Australia). Most patients in the studies came from minority or low-income populations.

  • Median intervention cost per person per year: $585 (13 studies)
  • Median change in healthcare cost per person per year: $72 reduction (4 studies)
  • Median cost per quality adjusted life year (QALY) gained: $38,276 (5 studies). This estimate falls below $50,000—a benchmark for cost-effectiveness.

Applicability

Based on results, the Task Force finding should be applicable to interventions that engage community health workers in the following settings and populations:

  • Adults with type 2 diabetes
  • Women and men
  • Hispanics, African-Americans, and Asians
  • Low-income and low-education populations
  • Urban and rural environments
  • Clinics, community, and home settings

Evidence Gaps

Additional research and evaluation are needed in these areas to fill existing gaps in the evidence base.

  • How effective are large-scale programs (i.e., >500 participants), programs conducted in rural settings, and programs evaluated over a longer time period?
  • What are the challenges or barriers that impact the recruitment and retention of male clients?
  • How will changes in Centers for Medicaid (CMS) reimbursement rules affect the use of community health workers and the roles and services they provide?
  • How effective are interventions among younger and older adult populations?
  • What are the long-term effects on diabetes-related complications and health outcomes?
  • How can community health workers be more engaged as outreach, enrollment, and information agents, patient navigators, and community organizers?
  • What are the roles and effects of community health workers in a team-based care environment?

Study Characteristics

  • Included studies had the greatest suitability of design (individual randomized control trials [15 studies], group randomized controlled trials [5 studies], before-after with a comparison group [5 studies], other design with concurrent comparison groups [5 studies]); moderate suitability of design (retrospective cohort [1 study]); and least suitability of design (before-after without a comparison group [13 studies]).
  • Studies were conducted in the United States (39 studies), the United Kingdom (3 studies), and Australia (2 studies).
  • Studies were conducted in urban (21 studies), rural (6 studies), or mixed (3 studies) areas; 14 studies did not report this information.
  • Included studies evaluated interventions in clinics (e.g., primary care settings, Federally Qualified Health Centers; 13 studies), community centers (e.g., YMCA, faith-based organization; 6 studies), homes (3 studies), or multiple settings (22 studies).
  • In the included studies, CHWs served adults ages 18–64 years old (32 studies), older adults ages 65 years and older (1 study), adults 18 years and older (3 studies), or patients of all ages (3 studies); 5 studies did not report this information.
  • Participants had type 2 diabetes (31 studies), type 1 or 2 diabetes (6 studies), or diabetes of unspecified type (7 studies).
  • Across all 44 studies, more than 70% of participants were female.
  • Included studies mainly focused on underserved populations and targeted the following populations:
    • Latinos (16 studies), African-Americans (2 studies), Asians (3 studies), Native Hawaiian or Pacific Islanders (2 studies study), and American Indians (2 studies)
    • Low-income populations (18 studies; annual incomes of $30,000 or less)
    • People with less than high school education (14 studies), or people who averaged less than 12 years of education (8 studies)
  • Community health workers engaged participants using a team-based care approach (17 studies), as a member of care delivery team (10 studies), or as the primary implementer (17 studies).
    • In the 27 team studies, the other team members were most often physicians (19 studies), nurses (15 studies), or registered dietitians (12 studies).
  • Community health workers met a median of 3.5 of the 10 core roles defined in the Community Health Worker Core Consensus (C3 Project, 2016). These included the following:
    • Providing culturally appropriate information (37 studies)
    • Building individual and community capacity (33 studies)
    • Coaching (32 studies)
    • Coordinating care or case management (17 studies)

Publications

Jacob V, Chattopadhyay SK, Hopkins DP, et al. Economics of community health workers for chronic disease: findings from Community Guide systematic reviews. American Journal of Preventive Medicine. 2019;56(3):e95-e106.

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