title: Integrating community health workers into a patient-centered medical home to support disease self-management among Vietnamese Americans: lessons learned.
abstract: There is evidence that patient-centered medical homes (PCMHs) and community health workers (CHWs) improve chronic disease management. There are few models for integrating CHWs into PCMHs in order to enhance disease self-management support among diverse populations. In this article, we describe how a community-based nonprofit agency, a PCMH, and academic partners collaborated to develop and implement the Patient Resource and Education Program (PREP). We employed CHWs as PCMH care team members to provide health education and support to Vietnamese American patients with uncontrolled diabetes and/or hypertension. We began by conducting focus groups to assess patient knowledge, desire for support, and availability of community resources. Based on findings, we developed PREP with CHW guidance on cultural tailoring of educational materials and methods. CHWs received training in core competencies related to self-management support principles and conducted the 4-month intervention for PCMH patients. Throughout the program, we conducted process evaluation through structured team meetings and patient satisfaction surveys. We describe successes and challenges associated with PREP delivery including patient recruitment, structuring/documenting visits, and establishing effective care team integration, work flow, and communication. Strategies for mitigating these issues are presented, and we make recommendations for other PCMHs seeking to integrate CHWs into care teams.
authors.affiliation: Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Wennerstrom
authors.affiliation: Mary Queen of Vietnam Community Development Corporation, New Orleans, LA, USA.
authors.forename: Tap
authors.initials: T
authors.lastname: Bui
authors.affiliation: Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Jewel
authors.initials: J
authors.lastname: Harden-Barrios
authors.affiliation: Tulane University School of Medicine, New Orleans, LA, USA eprice@tulane.edu.
authors.forename: Eboni G
authors.initials: EG
authors.lastname: Price-Haywood
mesh_terms: D001213:Asian; D057191:Capacity Building / Q000458:organization & administration; D002908:Chronic Disease; D003142:Communication; D003150:Community Health Workers / Q000193:education / Q000458:organization & administration*; D054521:Cultural Competency; D005260:Female; D006266:Health Education / Q000458:organization & administration*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D018802:Patient-Centered Care / Q000458:organization & administration*; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration*; D012648:Self Care / Q000379:methods; D014481:United States / Q000453:epidemiology; D014744:Vietnam / Q000208:ethnology
keywords: Vietnamese American; community health worker; diabetes; hypertension; patient-centered medical home