Amireh Ghorob

Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial

PURPOSE Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes. METHOD We undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA1C) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA1C level of 1.0% or more and proportion of patients with an HbA1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables. RESULTS At 6 months, HbA1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted). CONCLUSIONS Peer health coaching significantly improved diabetes control in this group of low-income primary care patients.

The 10 Building Blocks of High-Performing Primary Care

Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements—engaged leadership, data-driven improvement, empanelment, and team-based care—that assist the implementation of the other 6 building blocks—patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

The effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial.

BackgroundAlthough self-management support improves diabetes outcomes, it is not consistently provided in health care settings strained for time and resources. One proposed solution to personnel and funding shortages is to utilize peer coaches, patients trained to provide diabetes education and support to other patients. Coaches share similar experiences about living with diabetes and are able to reach patients within and beyond the health care setting. Given the limited body of evidence that demonstrates peer coaching significantly improves chronic disease care, this present study examines the impact of peer coaching delivered in a primary care setting on diabetes outcomes.Methods/DesignThe aim of this multicenter, randomized control trial is to evaluate the effectiveness of utilizing peer coaches to improve clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. A total of 400 patients from six primary health centers based in San Francisco that serve primarily low-income populations will be randomized to receive peer coaching (n = 200) or usual care (n = 200) over 6 months. Patients in the peer coach group receive coaching from patients with diabetes who are trained and mentored as peer coaches. The primary outcome is change in HbA1c. Secondary outcomes include change in: systolic blood pressure, body mass index (BMI), LDL cholesterol, diabetes self-care activities, medication adherence, diabetes-related quality of life, diabetes self-efficacy, and depression. Clinical values (HbA1c, LDL cholesterol and blood pressure) and self-reported diabetes self-efficacy and self-care activities are measured at baseline and after 6 months for patients and coaches. Peer coaches are also assessed at 12 months.DiscussionPatients with diabetes, who are trained as peer health coaches, are uniquely poised to provide diabetes self management support and education to patients. This study is designed to investigate the impact of peer health coaching in patients with poorly controlled diabetes. Additionally, we will assess disease outcomes in patients with well controlled diabetes who are trained and work as peer health coaches.Trial RegistrationClinicalTrials.gov identifier: NCT01040806

Expanding the Roles of Medical Assistants Who Does What in Primary Care

Adult primary care in the United States faces a dilemma. Many patients report poor access to their primary care clinician. Yet the growing demand for primary care leads to high levels of clinician burnout. A commonly voiced solution is to increase the numbers of adult primary care clinicians—physicians, nurse practitioners, and physician assistants. However, most workforce projections find that there will not be enough clinicians to meet the increasing demand.1 At the same time, many primary care activities do not require a clinician’s expertise, creating dissatisfied practitioners working well below their skill level. To meet the demand for primary care and to improve the work life of clinicians, it is sensible to redistribute responsibilities to other members of the primary care team. Some primary care practices expand the roles of nurses, pharmacists, social workers, and behavioral health professionals to improve patient access without further stressing clinicians. Many primary care practices, however, do not have nurses, pharmacists, or social workers. The clinical workforce in many practices consists of clinicians and low-paid unlicensed staff, in particular medical assistants. According to the Bureau of Labor Statistics,2 the median salary for medical assistants in 2012 was

Share the Care™: building teams in primary care practices.

29 370 compared with

How Do Peer Coaches Improve Diabetes Care for Low-Income Patients?: A Qualitative Analysis

65 470 for registered nurses. To utilize the staff that actually exists in most practices, clinicians should consider expanding the roles of medical assistants.

Building teams in primary care: A practical guide.

Everyone agrees that health care is a team sport. But creating and nurturing successful teams has proven to be difficult.[1][1] Basketball enthusiasts and primary care team champions agree that forming a dream team is not as simple as thrusting individuals into a group. To engage all team members

Diabetes Peer Coaching: Do “Better Patients” Make Better Coaches?

Purpose The purpose of the study was to explore the perspectives and roles of peer coaches, who are patients with diabetes trained to provide diabetes self-management support (DSMS) to other patients. Methods A focus group and 17 qualitative semi-structured interviews were conducted with community-based peer coaches in San Francisco in order to better understand the process by which these coaches engaged with their patients. Transcripts were coded and analyzed using methods based on grounded theory to develop a theoretical model of peer coach roles. Results Peer coaches play 3 principal roles in providing DSMS: advisor, supporter, and role model. While working with patients, peer coaches had different approaches to setting emotional boundaries and to allocating responsibility for implementing health behavior changes. Peer coaches were more consistent in how they sought resources from providers. Peer coaches also became empowered to better manage their own diabetes. Conclusion Peer coaches are a highly motivated potential workforce uniquely positioned to teach and empower patients by building trust through shared experiences. The variability in coaching styles suggests an inherent diversity among peer coaches that must be accounted for in future strategies for design, recruitment, training, and oversight of peer coaching programs.

Are Low-Income Peer Health Coaches Able to Master and Utilize Evidence-Based Health Coaching?

INTRODUCTION Primary care is changing to a team-based model. A number of high-performing primary-care practices in the United States have succeeded in making the transition to team-based care. METHOD Site visits were conducted to 29 high-performing primary-care practices. Observations made in these practices were summarized for common elements exhibited by care teams. A limited literature search was done to review corroborating evidence. RESULTS Teams observed in the 29 practices were found to exhibit 9 elements: a stable team structure, colocation, a culture shift in progress from physician-driven to team-based care, defined roles with training and skill checks to reinforce those roles, standing orders and protocols, defined workflows and workflow mapping, staffing ratios adequate to facilitate new roles, ground rules, and modes of communication, including team meetings, huddles, and minute-to-minute interaction. DISCUSSION These 9 elements may be helpful to practices making the transition to team-based care.

Sharing the Care to Improve Access to Primary Care

Purpose The purpose of this study was to identify characteristics of peer coaches associated with improvement in diabetes control among low-income patients with type 2 diabetes. Methods Low-income patients with type 2 diabetes who spoke English or Spanish from 6 urban clinics in San Francisco, California, were invited to participate in the study. Twenty participants received training and provided peer coaching to 109 patients over a 6-month peer coaching intervention. Primary outcome was average change in patient glycosylated hemoglobin (A1C). Characteristics of peer coaches included age, gender, years with diabetes, A1C, body mass index (BMI), levels of diabetes-related distress, self-efficacy in diabetes self-management, and depression. Results Patient improvement in A1C was associated with having a coach with a lower sense of self-efficacy in diabetes management (P < .001), higher level of diabetes-related distress (P = .01), and lower depression score (P = .03). Conclusions Coach characteristics are associated with patient success in improving A1C. “Better” levels of coach diabetes self-efficacy and distress were not helpful and, in fact, were associated with less improvement in patient A1C, suggesting that some coach uncertainty about his or her own diabetes might foster improved patient self-management. These coach characteristics should be considered when recruiting peer coaches.