The impact of trained community health workers on health care utilization and quality of life for diabetic Medicaid enrollees

Abstract

Volunteer Community Health Workers (CHW) have been used in the United States in various capacities, but their effectiveness have not been well established. The goal of the study was to measure the impact of the Community Health Worker interventions on Medicaid enrollees with diabetes. A quasi-experimental design was used to test the hypotheses that CHW interventions decreased health care utilization and improved the quality of life of Medicaid enrollees with diabetes from one year before the initiation of the CHW intervention through one year of operation. Subjects of the Medicaid patients who expressed interest in the CHW program were included in the evaluation. The intervention group consisted of those who had 5 or more CHW contacts, and the non-intervention group were those who expressed interest but had less than 5 CHW contacts. After completing a minimum of 40 hours of training, CHWs initiated contacts with patients, alternating phone calls and home visits. The intervention included: linking patients with appropriate health care providers, providing social support to patients, monitoring patients' self-care behaviors and signs of complications, and helping and monitoring patients physician's appointment keeping. The Maryland Medicaid and CHW databases were used for analyses. The outcome measures were quality of life (MOS SF-36 questionnaire) at baseline and six month follow-up, number of emergency room visits, number of hospitalizations, days of hospitalization stay, Medicaid health service reimbursements and consistency of diabetic therapy from one year before to one year after the intervention was initiated. Paired comparison t-tests were used to test for differences in the before and after measures. Multiple regression and analysis of covariance (ANCOVA) were used to assess the main effects of covariables (such as age, sex, diagnosis), independent variable (such as number of CHW contacts) and their interactions after adjustment for covariates (such as pre-intervention measures of study variables). Of the 543 respondents, 184 diabetic patients completed the MOS SF-36 questionnaire at baseline and about half (N = 95) completed it at six months follow-up. Of the 543 respondents, only 182 were able to be matched to the Medicaid database after applying study exclusion criteria. The results showed that CHW interventions improved patients' quality of life in six of eight dimensions from 1 to 14%, even though this patient population had much lower baseline scores when compared to those reported in other published studies. In analyzing health care utilization, the intervention group had decreased emergency room visits (49% less for in-patient emergency room visits), decreased hospitalizations, decreased days per hospitalization and reduced Medicaid health service expenditures. The non-intervention group had increases on each of these measures. These data strongly suggest that CHW interventions were effective in reducing numbers of emergency room visit and hospitalization and length of hospitalization for Medicaid enrollees with diabetes. Limitations of the study include selection bias, relatively small sample size and short period of evaluation. However, this study provides very encouraging information about the effectiveness of Community Health Workers, and should serve as a model for outcome research in program evaluation.