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Human beings are more effective and happier when they have someone they can talk to about personal matters who cares about them who can help them when.

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Presentation on theme: "Human beings are more effective and happier when they have someone they can talk to about personal matters who cares about them who can help them when."— Presentation transcript:

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2 Human beings are more effective and happier when they have someone they can talk to about personal matters who cares about them who can help them when they need help The risk of death associated with social isolation is greater than the risk associated with cigarette smoking House, Landis & Umberson. Science, : Holt-Lunstad, Smith, & Layton PLOSMedicine, 2010, 7: July e Harlow, H.F., & Harlow, M. (1966) Learning to love. American Scientist 54: Fundamental Role of Social Connections and Support

3 Chronic Disease & Prevention – 8,760 8,766 = 24 X hours a year in a doctor’s office or with other health professional. 8,760 hours “on your own” –Healthy diet –Physical activity –Monitor status –Take medications –Manage sick days –Manage stress – Healthy Coping –Arrange medical appointments and testing –Sleep

4 Diabetes Self Management Education and Diabetes Self Management Support Diabetes Self Management Education: Teaches what I need to do “Improvements in outcomes diminish after ~ 6 months” Diabetes Self Management Support Helps me plan and do what I need to do Support “to implement and sustain the behaviors needed to manage” diabetes Haas, et al. (2013). National Standards for Diabetes Self-Management Education and Support. Diabetes Care 36 Suppl 1, s100-s108.

5 Strengths of Peer Supporters Not professionals Often have the health problem they are assisting with – e.g., people with diabetes helping others with diabetes Share perspectives, experience of those they help Credibility regarding attitudes and capability because they are “like me” “The doctor tells me something is important. The peer supporter helps me figure out how I feel about it whether I can do it.” Can teach how to implement basic self management plans (e.g., healthy diet, physical activity, adherence to medications) Have time!!!

6 Review of Evidence Among Publications on Peer Support 01/01/2000 – 5/31/2011 : “peer support,” “coach,” “promotora” etc. 66 separate studies met criteria of: –Provided by nonprofessional –Support for multiple health behaviors over time (i.e., not isolated or single behaviors) –Not simply peer implementation of class Preliminary outcomes: –Significant within- or between-group changes: 83.3% of reports using controlled designs Elstad et al., Internat Cong Beh Med, Washington, D.C., August, 2010; Fisher et al., in preparation

7 peersforprogress.org

8 Peers for Progress Program of American Academy of Family Physicians Foundation Enhance Quality and Availability of Peer Support Worldwide 1.Build evidence base 2.Networking for QI, knowledge sharing, disseminating tools, social networking 3.Regional networks for program adoption, expansion, advocacy – National Peer Support Collaborative Learning Network

9 Original 14 Grantees Additional Collaborators

10 WHO Consultation, November, 2007 Australia Bangladesh Bermuda Brazil Cameroon Canada China Egypt Gambia India Indonesia Jamaica Mexico Netherlands Pakistan Philippines Saudi Arabia Singapore Switzerland (WHO) Turkey Ukraine United Kingdom United Republic of Tanzania United States 1.Key functions are global 2.How they are addressed needs to be worked out within each setting

11 Key Functions of Peer Support 1.Assistance, consultation in applying management plans in daily life 2.Social and Emotional Support 3.Linkage to clinical care 4.Ongoing support, extended over time Fisher et al. Fam Pract Suppl 1: i6-16.

12 KEY FUNCTIONS Assist in managing diabetes in daily life Social and emotional support Link to clinical care Ongoing support Diverse Implementation of Key Functions Local, Regional, Cultural Influences “Standardization by function, not content” Hawe et al. British Medical Journal 328: , Aro et al. Eur J Public Health 18: , 2008

13 Peer Support in San Francisco Thomas Bodenheimer, University of California, San Francisco Clinical Setting Six Department of Public Health safety-net primary care clinics serving patients covered by Medicare/Medical or San Francisco’s coverage for uninsuredresidents Majority of patients were non-white, ethnically and culturally diverse Patient Contact Patients had average of 7.02 interactions with their coach, inluding 5.37 telephoned calls Outcomes Reduction in HbA1c by > 1 point: 49.6% vs 31.5% HbA1c < 7.5%: 22% vs 14.9% Thom et al., Annals of Family Medicine :

14 Emerging Results from Projects Feasibility Sustainability Adoption Reach, Engagement Efficacy Effectiveness Implemented in all 14 project sites Mean baseline HbA1c = 8.92% Improved HbA1c, BMI, BP, QOL Uganda, South Africa without funding;  participation WellMed extends from 15 to all 23 sites

15 In FQHC in Denver, Peer Supporters Shifted costs away from urgent care, inpatient care, and outpatient behavioral health care Increase utilization of primary and specialty care visits. ROI = 2.28:1.00. (Whitley et al. J Hlth Care Poor Underserved : 6-15) Diabetes Initiative of the Robert Wood Johnson Foundation 3 of 4 projects in cost analysis emphasized peer supporters Cost per Quality Adjusted Life Year (QALY) = $39,563 (well below $50,000 criterion for good value) (Brownson et al., The Diab Educator : ) Asthma CHW Project with Medicaid Covered Children in Chicago Three to four CHW home visits over 6 mos and liaison with care team ROI: $5.58 saved per dollar spent (Margellow-Anast et al. J. Asthma : ) Cost Effectiveness

16 NCLR/IHH promotores programs Since the 1990s, NCLR has used the promotores de salud approach as one of its major intervention strategies in health programs targeting underserved Latinos NCLR’s research and extensive work with its Affiliate CBOs have demonstrated that: – promotores represent an effective health promotion model – have the greatest potential to increase awareness and promote positive behavior changes among Latinos NCLR’s success with promotores is unique because it has strived to establish conditions for replication and ensure rigorous evaluations of each promotores project

17 NCLR/IHH promotores programs ( cont’d) IHH has implemented a wide variety of highly effective health promotion activities that focus on training Latino community members as promotores de salud. Recent examples include: – Comprando Rico y Sano (Healthy and Delicious Grocery Shopping) store tour and nutrition education program – Viviendo Saludable (Living Healthy) diabetes education and self-management among older adults – Mantenga Su Mente Activa (Keep Your Mind Active) Alzheimer’s awareness and education – Mujer Sana, Familia Fuerte (Healthy Woman, Strong Family) cervical cancer education project

18 Distress and Chronic Disease

19 Simple Model of Comorbidity Chronic Disease e.g., Diabetes, Asthma, CHF, CVD Psychological Disorder e.g., Stress, Low Mood, Family Problems Depression, Anxiety Disorder

20 Chronic Disease and Psychological Disorders as Expressions of Complex Biological, Psychological, and Socioeconomic History Chronic Disease e.g., Diabetes, Asthma, CHF, CVD Psychological Disorder e.g., Depression, Anxiety Disorder, Personality Disorder Complex of Developmental, Biological, Psychosocial Determinants Communities Organizations Housing Social Networks Families Behavior Early Development Inflammatory Processes Metabolism Epigenetics Genetics

21  Morbidity Disability Mortality Costs  The Face of 21 st Century Illness Burden Peer Support Can Help!!!

22 Jade and Pearl in Hong Kong Juliana C. Chan and colleagues, Hong Kong Institute of Diabetes and Obesity; The Chinese University of Hong Kong; Prince of Wales Hospital JADE – Structured Care Management ( Chan et al. Diabetes Care : 977–982.) Algorithm and registry based care Initial appraisal and report to PCP Quarterly reports, including to patient Initial patient education session PEARL – Peer Support (Chan, Am Diab Assoc, June, 2012) Peers work through and trained by nurses Peer support classes Individual contacts: –Protocol: 12 over 12 mos –Average of 17 Nota Bene: JADE is the Control Group

23 20% Above Cut-Off for Appreciable Distress (Total Score on Depression, Anxiety and Stress Scale > 17) DASS – Depression Anxiety Stress Scale All ps < 0.05 (*Adjusted for DASS_Depression_Pre, DASS_Anxiety_Pre, and DASS_Stress_Pre) DDS – Diabetes Distress Scale Chan JC et al ADA 2012

24 20% Who Are Distressed  40% of Hospitalizations High Distress/No Peer Support Chan JC et al ADA 2012 Days Cumulative proportion (%) High Distress w/ Peer Support High Distress Low Distress w/ or without Peer Support

25 “Lady Health Workers” in Pakistan Reduce Post-Partum Depression Manual based intervention, “Thinking Healthy Programme” Promote change in thoughts likely to increase depression Practical problem solving Collaboration with family Rahman et al. Lancet : Arch Womens Ment Health : “Lady Health Workers” Completed 2ndry education Responsible for ≈ 100 households Primarily general health education and preventive maternal and child care Extending to TB and HIV detection and control ≈ 96,000 LHWs cover 80% of Pakistan rural population

26 Reaching the Hard-to-Reach Reaching the Hard-to-Reach Hardly Reached

27 Peer Support in San Francisco Thomas Bodenheimer, University of California, San Francisco Clinical Setting Six Department of Public Health safety-net primary care clinics serving patients covered by Medicare/Medical or San Francisco’s coverage for uninsuredresidents Majority of patients were non-white, ethnically and culturally diverse Patient Contact Patients had average of 7.02 interactions with their coach, inluding 5.37 telephoned calls Outcomes Reduction in HbA1c by > 1 point: 49.6% vs 31.5% HbA1c < 7.5%: 22% vs 14.9% Thom et al., Annals of Family Medicine :

28 In San Francisco, Greater Improvements Among Those With Low Initial Medication Adherence Moskowitz et al. J Gen Intern Med. Online: 2/13/13

29 20% Who Are Distressed  40% of Hospitalizations High Distress/No Peer Support Chan JC et al ADA 2012 Days Cumulative proportion (%) High Distress w/ Peer Support High Distress Low Distress w/ or without Peer Support

30 Peer Support in Southern California Guadalupe X. Ayala – San Diego State University & Clinicas de Salud del Pueblo, Inc. Puentes – 12-months peer support provided by volunteers Patients – Recruited through FQHCs along US-Mexico border 43% 6 th grade education or less Peer Support – Phone, in-person, mail Problem-solved barriers to medication use Developed interpersonal skills: communicating needs with family members engaging family in supporting healthy diet and being active Provided opportunities for physical activity Connected patients with health care providers to provide ongoing support over time HbA1c %

31 Asthma Coaches Reach Hardly Reached Substantive Contact (Face-to-face or by phone in which at least one key management behavior discussed) 35% within 7 days of assignment of Coach 63% with 1 month 89% within 3 months Sustained Engagement: ≥ 1 contact per quarter throughout last year of 2-year intervention

32 Hospitalizations Admissions in Year Prior to Randomization (Year Pre) and 1st and 2nd Years of Coach Program Interaction of Group X Time significant, p <.02. Year 1 is adjusted by subtraction of index hospitalization. Thus Year 1 mean reflects hospitalizations other than index. Fisher et al. Arch Ped & Adol Med (3),

33 “Lady Health Workers” in Pakistan Reduce Post-Partum Depression Manual based intervention, “Thinking Healthy Programme” Promote change in thoughts likely to increase depression Practical problem solving Collaboration with family Rahman et al. Lancet : Arch Womens Ment Health : “Lady Health Workers” Completed 2ndry education Responsible for ≈ 100 households Primarily general health education and preventive maternal and child care Extending to TB and HIV detection and control ≈ 96,000 LHWs cover 80% of Pakistan rural population

34 Problem-Solving, Cognitive Behavioral Intervention delivered by “Lady Health Workers” Eliminates Effects of Non-Empowerment on Post-Partum Depression in Pakistan Rahman et al. The British Journal of Psychiatry :

35 PCMH and Reaching Populations

36 Community Outreach is Key Component of Patient-Centered Medical Home However, several challenges: Time consuming nurturing of community relationships Imprecise reach of community outreach: – Community programs and activities on weight management – Attended by “vegans who run marathons”

37 Peer Support for Outreach/Engagement from PCMH Peer supporters recruited from communities intended to reach – Community ties then intrinsic to services Peer supporters can reliably reach those of greatest importance – e.g., 92% of low-income, single mothers from ethnic minorities in Asthma Coach (Fisher et al. Arch Pediatr Adolesc Med Mar;163(3): ) Currently testing in collaboration with Alivio Medical Center, Chicago, National Council of La Raza, TransforMED©

38 Community Clinical Resources Compañeros en Salud Primary Care – Patient- Centered Medical Home Social, Emotional Support Ongoing Support for DSM: 4,000 and 400 Linkage: EMR, Reciprocal Referrals, Case Huddles, Extender of DSME, Beh Change Goals Person With Diabetes Alivio Medical Center – Peers for Progress – NCLR

39 Alivio Medical Center Reaching Entire Population of Adults with Diabetes Approximately 4500 with diabetes High Priority – HbA1c > 8%, Psychosocial Distress, Physician’s Referral 450 of the 4,500 Individual contact biweekly, then monthly Focus on regular care, diet, exercise, emotional support, assistance with other problems Normal Priority – Support groups, activities, contacts at clinic visits Total Contacted by Group: High Priority Normal Priority

40 What’s Next???

41 Reducing Rehospitalization Plan for discharge earlier Offer more intense education for new diagnoses Flag high-risk patients and provide case management Multidisciplinary approach to discharge Check in with patients with chronic conditions Follow up care Reconnect with PCPs The Revolving Door: A Report on U.S. Hospital Readmissions. RWJF February, 2013.

42 Follow Up After Major Procedures Joint replacement Transplant MIs, other major events Behavioral Health/Mental Health Schizophrenia Depression Emotional distress complicating other health problems

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44 Diabetes, Depression, Multi-Morbidity and Health in the 21st Century. Edwin Fisher, Ph.D., Global Director, Peers for Progress. December, 2012 Peer Support in U.S. Health Reform: Opportunities under the Affordable Care Act. Maggie Morgan and Amy Katzen, Center for Health Law and Policy Innovation, Harvard Law School. March, 2013 Lessons in State and Local Advocacy for Program Development. Carmen Velásquez, MA, Founder & Executive Director, Alivio Medical Center, Chicago. June, 2013 Resources for Outreach and Enrollment in the Health Insurance Marketplace with CMS. Jeanette Contreras, MPP, Office of Communications, Centers for Medicare & Medicaid Services. September, 2013 Peer Support, Motivational Interviewing, and Adults Living with AIDS. Carol Golin, MD, University of North Carolina-Chapel Hill. December, 2013 Webinars

45 November 13: Generate options for topics on which to focus in 2014, e.g. o Peer support in PCMH o Peer support in integrating behavioral health o Fulfilling the promise of ACA for CHW programs Generate options for modes, channels, approaches to pursuing topics, e.g. o Program guides or resources o Policy brief, advocacy plan o Curating samples of model programs November 14 – mid-December Staff development of options Refine options through circulation and feedback Webinar, mid-December Finalize priorities and strategies for pursuing them


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