Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
Bellevue Hospital Center, New York, NY, USA.
J Gen Intern Med. 2024 Apr;39(5):774-781. doi: 10.1007/s11606-023-08512-w. Epub 2023 Nov 16.
Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus ("diabetes"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role.
Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care.
Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital.
CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs.
Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis.
CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload.
CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.
超过三分之一的美国成年人被诊断患有前驱糖尿病，其中 70%可能进展为 2 型糖尿病（“糖尿病”）。社区卫生工作者（CHW）可以帮助患者采取健康行为来预防糖尿病。然而，将 CHW 纳入初级保健的指导有限，特别是在解决 CHW 的双重基于诊所和面向社区的角色方面。
利用纽约市安全网医院中 CHW 对糖尿病预防干预措施的适应性改变的证据，我们研究了 CHW 行为对计划保真度的性质、意图和可能后果。我们提出了将 CHW 纳入初级保健的策略。
案例研究借鉴适应性设计和影响模型（MADI），分析 CHORD（社区健康外展以减少糖尿病）实施过程中 CHW 的行为，这是一项在曼哈顿退伍军人事务部和贝尔维尤医院进行的基于群组的实用试验（2017-2022）。
CHORD 研究中的 CHW 和临床医生，本分析重点关注 CHW。
对 CHW 进行半结构化访谈和焦点小组讨论（n=4）；对临床医生进行半结构化访谈（n=17）。采用解释主义方法，通过归纳和演绎分析相结合，解释 CHW 的适应性变化。
CHW 的适应性改变以三种方式扩展了干预措施：通过扩展社会援助、医疗保健获取和运营任务。这些适应旨在提高适应性、覆盖范围和保留率，但可能对实施结果产生连锁反应。CHW 对患者复杂社会需求的关注可能会使他们偏离明智地管理其病例的目标。
CHW 的社区知识可以支持患者参与，但社会援助的过度扩展可能会影响到基于协议的健康指导目标。初级保健中的 CHW 计划应明确划定 CHW 向患者提供的非健康支持，包括多专业团队或与社区组织的合作关系，建立 CHW 和临床医生之间的正式沟通，并制定机制来审查和迭代 CHW 的工作，以解决其社区导向角色中的挑战。
