Transcript Title of Talk - Peers For Progress

Fundamental Role of
Social Connections and Support
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, 1988 241: 540-544.
Holt-Lunstad, Smith, & Layton PLOSMedicine, 2010, 7: July e1000316
www.plosmedicine.org
Harlow, H.F., & Harlow, M. (1966)
Learning to love. American Scientist
54: 244-272.
Chronic Disease & Prevention – 8,760
8,766 = 24 X 365.25
6 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
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.
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!!!
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
peersforprogress.org
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
Original 14 Grantees
Additional Collaborators
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
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 2010 27
Suppl 1: i6-16.
“Standardization by function, not content”
Hawe et al. British Medical Journal 328:1561-1563, 2004.
Aro et al. Eur J Public Health 18:548-549, 2008
Local, Regional,
Cultural
Influences
KEY FUNCTIONS
Assist in managing
diabetes in daily life
Social and emotional
support
Link to clinical care
Ongoing support
Diverse
Implementation
of Key
Functions
Peer Support in San Francisco
Thomas Bodenheimer, University of California, San Francisco
Clinical Setting Six Department
of Public Health safety-net
0
primary care clinics serving
patients covered by
-0.5
Medicare/Medical or San
Francisco’s coverage for
-1
uninsuredresidents
Changes in HbA1c at
6 Months (p = 0.01)
Usual
Care
Coach
-1.5
 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 2013 11: 137-144.
Emerging Results
from Projects
Feasibility
Implemented
in all 14
project sites
Reach,
Engagement
Efficacy
Effectiveness
Mean
baseline
HbA1c =
8.92%
Improved
HbA1c, BMI,
BP, QOL
Sustainability
Uganda,
South Africa
without
funding; 
participation
Adoption
WellMed
extends from
15 to all 23
sites
Cost Effectiveness
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 2006 17: 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. 2009 35: 761-769)
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 2012 49: 380-389)
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
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
Distress and
Chronic Disease
Simple Model of Comorbidity
Chronic Disease
e.g., Diabetes, Asthma,
CHF, CVD
Psychological
Disorder
e.g., Stress, Low Mood,
Family Problems
Depression, Anxiety Disorder
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
The Face of 21st Century Illness Burden

Morbidity
Disability
Mortality
Costs

Peer Support Can Help!!!
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 2009 32: 977–982.)
•
•
•
•
Algorithm and registry based care
Initial appraisal and report to PCP
Quarterly reports, including to patient
Initial patient education session
Nota Bene:
JADE is the
Control Group
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
20% Above Cut-Off for Appreciable Distress
(Total Score on Depression, Anxiety and Stress Scale > 17)
Change Scores
Depression
Anxiety
Stress
Total
0
-2
-4
-6
-8
Structured Care
Structured Care + Peer
Support
-10
-12
-14
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
Cumulative proportion (%)
20% Who Are Distressed
 40% of Hospitalizations
High Distress
Distress/No Peer Support
Low Distress w/
or without
Peer Support
High Distress w/
Peer Support
Days
Chan JC et al ADA 2012
“Lady Health Workers” in Pakistan Reduce
Post-Partum Depression
“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
Rahman et al.
Lancet 2008 372: 902-909
Arch Womens Ment Health 2007 10: 211-219.
Manual based intervention, “Thinking
Healthy Programme”
• Promote change in thoughts likely
to increase depression
• Practical problem solving
• Collaboration with family
Reaching the
Hard-to-Reach
Hardly Reached
Peer Support in San Francisco
Thomas Bodenheimer, University of California, San Francisco
Clinical Setting Six Department
of Public Health safety-net
0
primary care clinics serving
patients covered by
-0.5
Medicare/Medical or San
Francisco’s coverage for
-1
uninsuredresidents
Changes in HbA1c at
6 Months (p = 0.01)
Usual
Care
Coach
-1.5
 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 2013 11: 137-144.
In San Francisco, Greater Improvements Among Those With
Low Initial Medication Adherence
Moskowitz et al. J Gen Intern Med. Online: 2/13/13
Cumulative proportion (%)
20% Who Are Distressed
 40% of Hospitalizations
High Distress
Distress/No Peer Support
Low Distress w/
or without
Peer Support
High Distress w/
Peer Support
Days
Chan JC et al ADA 2012
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% 6th grade education or less
Peer Support – Phone, in-person, mail
HbA1c %
10
9
8
7
6
Baseline 6 Months
12
Months
Control
• Problem-solved barriers to medication use
Puentes
• 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
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
Hospitalizations
Admissions in Year Prior to Randomization (Year Pre) and
1st and 2nd Years of Coach Program
1.2
1
0.8
Control
Coach
0.6
0.4
0.2
0
Year Pre
Year 1
Year 2
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 2009 163 (3), 225-232.
“Lady Health Workers” in Pakistan Reduce
Post-Partum Depression
“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
Rahman et al.
Lancet 2008 372: 902-909
Arch Womens Ment Health 2007 10: 211-219.
Manual based intervention, “Thinking
Healthy Programme”
• Promote change in thoughts likely
to increase depression
• Practical problem solving
• Collaboration with family
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 2012 201: 451-457
PCMH and
Reaching
Populations
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”
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. 2009 Mar;163(3):225-32.)
Currently testing in collaboration with Alivio Medical
Center, Chicago, National Council of La Raza,
TransforMED©
Alivio Medical Center – Peers for Progress – NCLR
Person
With
Diabetes
Clinical
Resources
Primary
Care –
PatientCentered
Medical
Home
Linkage: EMR, Reciprocal
Referrals, Case Huddles,
Extender of DSME,
Beh Change Goals
Ongoing Support for DSM:
4,000 and 400
Social, Emotional Support
Compañeros
en
Salud
Community
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
What’s Next???
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.
Follow Up After Major Procedures
• Joint replacement
• Transplant
• MIs, other major events
Behavioral Health/Mental Health
• Schizophrenia
• Depression
• Emotional distress complicating other health
problems
Webinars
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
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 email
circulation and feedback
Webinar, mid-December
• Finalize priorities and strategies for
pursuing them