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Evidence-Based Diabetes Management July 2014

Diabetes Navigator Program Reduces A1C Levels for Patients in Alabama

Mary K. Caffrey
ADA 74th Scientific Sessions
Deploying diabetes patient navigators among patients in Birmingham, Alabama, who were at high risk for developing type 2 diabetes mellitus (T2DM) produced measurable reductions in glycated hemoglobin (A1C) levels, and increased the patients’ perception that their care was improving, according to researchers who presented results at the 74th Scientific Sessions of the American Diabetes Association.

In 2012, the American Academy of Family Physicians Foundation (AAFP) and Sanofi US launched a collaboration to not only better connect T2DM patients with community resources, but also to convince those at risk that they could manage their disease. Results from the effort, called Cities for Life, were reported June 14, 2014, during the ADA meeting, which was held at the Moscone Center in San Francisco, California.

“Diabetes care involves patients doing what they need to do every day, 24/7, 365 days a year. Leading a healthy lifestyle makes all of the medicines work better,” said Edwin Fisher, PhD, of the AAFP Foundation. Yet patients who live in “food deserts” or have few safe places to exercise may have a hard time maintaining healthy lifestyles, Fisher said.

Cities for Life aimed to fill that gap. The program connected patients already diagnosed with T2DM or those at risk of developing the disease with navigators, who not only helped identify local resources to help patients manage their disease, but also gave patients education and encouragement about why a healthy lifestyle mattered. Patients were assigned to a navigator by their primary care physician (PCP). While some elements of Cities for Life were available to everyone in Birmingham, including a website with diabetes care resources, a group of 179 at-risk patients were tracked closely. Most in this group (77.5%) were African American women, and nearly all were overweight or obese. Patients in the closely watched group heard from navigators an average of 6 times during the intervention.1

Fisher said Cities for Life benefited from enthusiastic, highly effective navigators as well as the participation of 80 community leaders who served on an advisory board. One Birmingham City Council member took a special interest in the program, Fisher said, ensuring that it would receive staff support and followup. Community leadership and awareness makes a difference, Fisher said.

Abstracts presented at ADA included a presentation of outcomes, with Natalia Loskutova, MD, PhD, as the lead author. Data showed that the 179 closely watched subjects started the 9-month intervention with average A1C levels of 7.7% and were able to drop that average to 7.1%. Slight improvements were seen in blood pressure and cholesterol levels, and patients reported improvements in their perceived ability to manage their disease.1

Fisher said AAFP and Sanofi purposely selected Birmingham because it is located in a state that is among the top 10 in the country in T2DM incidence, and where health problems among the poor have long been seen to be intractable.2 By going “to where the problem is,” Fisher said, researchers hoped to show the potential value of patient navigators, whose role could be replicated within a Patient Centered Medical Home.

What makes a good navigator? Fisher said while most of the navigators in the Birmingham study had at least a bachelor’s degree, professional credentials were less important than having the right personal qualities. “They have to be reliable, caring, and have ‘emotional intelligence.’ They have to be willing to be part of team,” Fisher said. Navigators needed to  understand when to push a little harder, when to hold back, and when a problem required a referral to a PCP or specialist.

How replicable is Birmingham’s experience? “What’s replicable is how we tailored it to the community,” Fisher said. He was the formal presenter of a separate abstract that analyzed the program’s effectiveness at the community level. Survey results showed Cities for Life increased community awareness of diabetes and patients’ perceptions of support.3

The project also revealed another challenge: the gap between providers’ and patients’ views of the level of family support for those with T2DM.4

1. Loskutova N, Tsai AG, Fisher EB. Cities for life: outcomes of integrating navigators in diabetes self-management. Diabetes. 2014;63(suppl 1): Abstract 671-P.

2. Page P. Medicaid expansion choices mean different care for poor diabetics, depending on where they live. Am J Manag Care. 2014;20(SP8) SP239-SP240.

3. Turner T, Jones L, Thompson J, et al. Cities for life: comprehensive community organization for diabetes in Birmingham, Alabama. Diabetes. 2014;63(suppl1): Abstract 707-P.

4. Loskutova N, Tsai AG, Fisher EB. Cities for life: changing discordant perspectives regarding diabetes management. Diabetes. 2014;63(suppl 1): Abstract 708-P.
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