Methods: The clinical and behavioral outcomes of the patients in three patient navigation programs are summarized and evaluated in this presentation. All community health workers in the programs received 160 hours Texas certified training curriculum. Patient Navigation Demonstration program (2008-2010) was the first patient outreach program for chronic disease management using TFH framework. A total of 183 patients with at least one of the following chronic diseases were enrolled in this program: Type II Diabetes, Hypertension and Asthma. Both clinical and behavioral outcomes of the patients were improved through the program. Patient Navigation Program (2010-2013) was the second funded patient outreach program using TFH framework. A total of 147 patients with either diabetes or hypertension or both were enrolled to the program. Interprofessional Collaborative Practice (IPCP) program (2014-2017) for cardiovascular risk reduction has been funded through HRSA in 2014.A total of 240 patients have been enrolled since 2014. Clinical measurements such as HgA1c, blood pressure, and lipid profiles were monitored clinical improvements. The Patient Health Questionnaire, SF-12, Self Efficacy for Diabetes Management Survey (SED), Self Efficacy for Managing Chronic Disease (SEMCD) instrument, Summary of Diabetes Self Care Activities (SDSCA) Questionnaire and Social Provisions Scale (SPS) were used to monitor behavioral changes. Growth curve analysis, paired t-test and mixed model are used to determine the effectiveness of the program. Additional measurements such as medication adherence rate, Generalized Anxiety Disorder 7-item (GAD-7) score, PHQ-9 depression score and clinical visits data from EMR have also been collected.
Results: For the first demonstration program-- The HbA1c for patients with diabetes was reduced from an average of 9.3% to 8.4% (p<0.05). The percentage of asthma patients with ER visits within 12 months before enrollment was 50% and none of them had ER visit during the program period. The behavioral scores for SF-12, Self Efficacy for diabetes, personal resource inventory, Self Efficacy for Managing Chronic Disease, Social Provisions Scale and Summary of Diabetes Self Care Activities were also significantly improved through the program.
For the second patient navigation program--The growth curve analysis shows that 70 patients with diabetes had significantly decreased their HgA1C level (p=.0096) during the navigation period (9.7±5.3months). Paired t-tests show that most of the behavioral outcomes were significantly improved through program. The Mental Health Composite Scale score of SF-12 was improved in an average of 6.21 [2.22, 10.19] (p=0.0029). The SED and SEMD Scores were both improved significantly, 1.38 [0.72, 2.04] (p=0.0002) and 0.68 [0.06, 1.30] (p=0.0334), respectively. Three out of five subscales of SDSCA, general diet, blood sugar test and foot check, were also improved significantly, 0.86 [0.22, 1.50] (p=0.0103), 1.49 [0.45, 2.53](p=0.0064), and 0.69 [0.07, 1.31] (p=0.0298), respectively.
For the IPCP program --Baseline data show that 65% of patients enrolled (N = 168) have two or more chronic conditions, 49% are on five or more prescription drugs, over 64% are unfunded, and over 25% are Medicaid/Medicare participants. Hypertension is the leading chronic condition (89.7%), followed by diabetes (68%), obesity (80.6%), dyslipidemia (22.2%), existing coronary artery disease (13.6%), asthma/COPD (7.8%) and other chronic conditions (33.5%). 14.8 percent of the patients had mild depression, and over 15.2% had moderate to severe depression (measured by PHQ-9) at baseline.
The collection of post-intervention data is ongoing, some of the behavioral outcomes collected at baseline (<45 days of enrollment), half-year (45 days-180 days), and one year (>=180 days) are listed in the table below.
|
Baseline |
Half-Year |
One year |
|
|
SF-12 v2 PCS MCS |
43.9±12.9 48.9±19.0 |
41.7±10.9 50.6±9.7 |
37.2±10.7 47.9±14.7 |
|
PHQ-9 |
7.0±6.5 |
10.5±6.9 |
7.3±6.6 |
|
SEMCD |
8.4±1.6 |
7.4±2.1 |
7.6±1.6 |
|
SED |
7.3±1.7 |
7.8±1.8 |
8.0±2.0 |
In year 2016, 70.7% of the HTN participants had controlled blood pressure and 45.4% of Diabetes participants had HbA1c<8%.
Conclusion: The patient navigation/outreach programs using TFH framework in delivering services, effectively promoted chronic disease management among vulnerable populations. Interprofessional team has been a valuable component of the program.