Program improves Latino population compliance

Insurer collaborates with free clinic to improve care

As part of its commitment to eliminating racial and ethnic disparities in health care, CareFirst BlueCross Blue Shield has launched a diabetes disease management program in collaboration with a Washington, DC, clinic that serves a mostly Latino population.

"The Latino population tends to do less well clinically and tend to adhere less closely to treatment guidelines for diabetes. Even in a majority white population, people with diabetes are far from being compliant. With minorities, we are lucky if we get 30% compliance with evidence-based guidelines," says Jon Shematek, MD, vice president, quality and medical policy of the Owings Mill, MD-based health plan, which covers members in Maryland; Washington, DC; Northern Virginia; and Delaware.

The health plan is collaborating with La Clinica del Pueblo on a pilot project to find out effective ways of improving diabetes care in a Latino population.

"The clinic has a large Latino clientele, with 90% to 95% of the patients preferring Spanish as their first language. Many of them have no insurance or are covered by public funding," he says.

The program is targeted to the community as a whole, not just patients that CareFirst BlueCross Blue Shield insures.

"This program is part of our commitment to improve community health. Most of the participants in this program are uninsured. Our intention is to prove that this model will work and build on it," Shematek says.

The health plan has received national recognition for a program that is ahead of the curve in terms of disease management for minorities, he says.

"If health plans are looking at changes in the demographics of the community they serve, this kind of program is good business," he says.

A large number of patients at La Clinica del Pueblo have diabetes and are not doing well when it comes to keeping their disease under control and staying out of the emergency department, he adds.

When the staff at La Clinica del Pueblo entered the information on the 150 patients in the pilot program from paper-based records into the database, they discovered that almost 30% had a hemoglobin A1C level greater than 8 and that 13% had a level that was greater than 10, a clear indication that diabetes is out of control. In the previous year, only 30% had an eye exam and 10% did not have a blood test.

In the first nine months of the program, before all of the components were in place, the number of patients who had not had a hemoglobin A1C test was cut in half and those with a good hemoglobin A1C level had risen from 52% to well over 60%, Shematek says.

"We worked closely with the medical director and clinical staff to develop ways to improve compliance in the clinic's population," he says.

The project has a three-pronged approach that includes technology, culturally competent care, and community-based peer educators.

"Taking care of people with diabetes is complicated, and physicians have to remember an extensive list of things that need to be checked, including blood tests, eye exams, foot care. There's a huge laundry list, and it can't be done efficiently with a paper-based system. The team approach to caring for a patient with diabetes begins with the implementation of technology," he says.

The health plan funded a computer system that the clinic can use to implement the chronic care model for helping patients manage their diabetes.

"The model uses the team approach so that the moment a patient checks into the clinic, the staff is able to engage the patient immediately and start talking about what tests are needed and provide education. This allows the doctors to focus on specific aspects of care," he adds.

The health plan also is providing funding for the three-year pilot project that includes funds for a bilingual, bicultural health educator to work with the diabetic population.

"A key to compliance is having someone who not only speaks the language but who is culturally competent as well. It's not enough to translate the treatment plan into Spanish. There has to be someone who understand the culture and who can provide culturally competent counseling with individual patients," he says.

In addition to working with diabetics one-on-one, the health educator is using group counseling, a highly effective and efficient way for people to learn from each other, he adds.

The health educator has developed a curriculum for the third phase of the program — the use of lay health workers, called promotores, or health promoters, who will work with the most challenging patients in their home.

"This model has been very successful in other countries, and we think it will work well here. The promotores will visit the homes once a month and work with people who are having problems with compliance. This is a wonderful way to break down the barriers of mistrust that occur by having a peer reinforce the message of the clinic," he says.

The clinic recruited the promotores from among its patient population, looking for people who are well respected in the community. Many have some kind of background in health care in their native country but are not necessarily qualified as a health care professional in America.

The promotores were recruited and trained over the summer and made their first home visits in September, reporting their findings to the clinical staff, who will use the information to know where to focus on the patient's next visit.

"It's a comprehensive and focused program to meet the needs of the patient," he says.

The overall aim of the program is to increase the level of trust among clinicians and the immigrant population, ultimately resulting in changed behavior, Shematek points out.

"Disease management is about changing behavior. It is most effective when the education is done by someone who speaks the language, understands the culture, and generates a level of trust," he says.

For instance, since controlling diabetes largely depends on nutrition, diet, and exercise, the CareFirst program has the advantage of having someone doing the educating who is familiar with the types of food the Latino population enjoys. She can come up with recipes that the patients are likely to use, rather than steering them toward unfamiliar foods, he adds.

"There are a lot of issues around health beliefs that are culturally unique. For a disease management plan to be effective, it must be coordinated by someone who understand how health care is sought, to what extent it is sought, and how members of that particular population communicate with the physicians and nurses," he says.

Someone who is a peer and understands the culture can gain the patient's trust and find out why he or she may not be following the guidelines, he points out.