Impact of a Community Health Worker–Led Diabetes Education Program on Hospital and Emergency Department Utilization and Costs

From Baylor Scott & White Health.

Abstract

• Objective: To assess the impact of a community health worker–led diabetes education program (DEP) on hospital utilization trends and to evaluate the return on investment.
• Methods: A retrospective, pre-post study design was used to examine differences in inpatient and emergency department (ED) utilization and costs for DEP patients in the year prior to and following enrollment. Patients with diabetes who received care at the same clinics but who were not enrolled in DEP served as a control group. Analysis of covariance was used to test for differences in utilization outcomes between DEP patients and controls, controlling for age, sex, and ethnicity.
• Results: DEP patients had a significant reduction in mean inpatient encounters (0.08 vs. 0.18), LOS per inpatient encounter (0.28 vs. 0.67), and inpatient cost per patient ($406 vs. $902) following DEP enrollment. Patients in the control group also experienced a significant reduction in inpatient LOS and costs. Neither group experienced a significant difference in ED utilization or costs. Return on investment for DEP was –66%, as the annual cost savings generated per patient from reduced utilization ($137.19) were less than the annual DEP costs (investment) per patient ($402.80).
• Conclusion: CHW-led diabetes education programs like DEP may provide additional benefits than can be gained from access to primary care alone in terms of avoidance of costly hospitalizations for diabetes-related complications. Although the DEP did not generate an overall cost savings for the health care system in the short term, additional savings may be generated in the long term through reductions of diabetes-related complications.

Diabetes poses a significant burden on the population of the United States in terms of morbidity, mortality, and costs of care. Currently, 29.1 million people in the United States have diabetes [1], and it is expected that 1 in 3 people could have diabetes by the year 2050 [2]. The economic impact of diabetes is also significant; as of 2012, 1 in 5 health care dollars went towards diabetes care [3], and the total cost of diabetes was estimated to be $245 billion [1]. This rapid increase in the incidence of diabetes and associated costs emphasizes the need for cost-effective strategies to prevent and manage diabetes within the U.S. population.

One strategy that has shown success in improving diabetes care and outcomes is the use of community health workers (CHWs) to deliver disease education and management programs. A CHW is a front-line public health worker who is often a trusted member of the community and has the capacity to influence patient understanding, enhance patient compliance, and promote more equitable practices in patient care management [4–6]. Several studies have shown that CHW-led interventions in diabetes management can help patients achieve control over their disease and improved health indicators such as HbA1c, blood pressure, lipid levels, and weight [7–17]. In addition, a few studies have shown that CHW-led interventions for patients with diabetes can help these patients avoid costly health care utilization in the form of emergency department (ED) visits and hospitalizations. Fedder et al found that diabetes patients on Medicaid who worked closely with CHWs experienced a decrease in ED visits (38%), hospitalizations (30%), and hospital admissions from ED (53%) [11]. This CHW intervention was associated with improved patient quality of life and a cost-savings of $2245 per patient per year for a total savings of $262,080 for 117 patients. More recently, a 2010 randomized controlled trial showed that African-American patients with diabetes who worked with a nurse case manager and a CHW were 23% less likely to make ED visits than those who just had a nurse case manager [18].

Despite the documented successes of CHW programs, the CHW model has not been widely adopted within integrated health care systems. A major barrier to adoption of CHW programs has been the lack of sustained funding for CHW services [17,19]. Historically, many CHW programs were supported by grants, as most payers were unwilling to fund these initiatives [4,17,19.] In 2008, the Centers for Medicare and Medicaid Services provided a mechanism to support CHW activities by approving a Medicaid state plan amendment authorizing payment for CHWs who worked under Medicaid-approved providers, such as physicians and nurses [19]. However, the lack of data available regarding the costs, cost-effectiveness, and potential costs savings of CHW programs continues to serve as a barrier to adoption [13,20].

Baylor Scott & White Health North (BSWH), formerly Baylor Health Care System in Dallas, Texas, created the CHW-led Diabetes Equity Project, a 5-year program supported with funding from Merck Foundation’s Alliance to Reduce Disparities in Diabetes, with the goal of reducing observed disparities in diabetes care and outcomes in the medically underserved, predominantly Hispanic communities surrounding BSWH hospitals [16,21,22]. The program featured specially trained, bilingual CHWs who served as members of primary care teams in 5 community clinics and delivered a culturally relevant diabetes self-management and education curriculum (DSME) targeting barriers to diabetes management commonly experienced by Hispanics. The objective of this study was to assess the impact of a CHW-led diabetes educucation program (DEP) on hospital utilization trends and to evaluate the return on investment of the program.