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Integrating Community Health Workers' Dual Clinic-Community Role in Safety-Net Primary Care: Implementation Lessons from a Pragmatic Diabetes-Prevention Trial

Gore, Radhika; Engelberg, Rachel S; Johnson, Danielle; Jebb, Olivia; Schwartz, Mark D; Islam, Nadia
BACKGROUND:Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus ("diabetes"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role. OBJECTIVE:Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care. DESIGN/METHODS:Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital. PARTICIPANTS/METHODS:CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs. APPROACH/METHODS:Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis. KEY RESULTS/RESULTS:CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload. CONCLUSIONS:CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.
PMID: 37973708
ISSN: 1525-1497
CID: 5610452

Implementation fidelity to a behavioral diabetes prevention intervention in two New York City safety net primary care practices

Gupta, Avni; Hu, Jiyuan; Huang, Shengnan; Diaz, Laura; Gore, Radhika; Levy, Natalie; Bergman, Michael; Tanner, Michael; Sherman, Scott E; Islam, Nadia; Schwartz, Mark D
BACKGROUND:It is critical to assess implementation fidelity of evidence-based interventions and factors moderating fidelity, to understand the reasons for their success or failure. However, fidelity and fidelity moderators are seldom systematically reported. The study objective was to conduct a concurrent implementation fidelity evaluation and examine fidelity moderators of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, cluster-randomized, controlled trial to test the impact of a Community Health Workers (CHW)-led health coaching intervention to prevent incident type 2 Diabetes Mellitus in New York (NY). METHODS:We applied the Conceptual Framework for Implementation Fidelity to assess implementation fidelity and factors moderating it across the four core intervention components: patient goal setting, education topic coaching, primary care (PC) visits, and referrals to address social determinants of health (SDH), using descriptive statistics and regression models. PC patients with prediabetes receiving care from safety-net patient-centered medical homes (PCMHs) at either, VA NY Harbor or at Bellevue Hospital (BH) were eligible to be randomized into the CHW-led CHORD intervention or usual care. Among 559 patients randomized and enrolled in the intervention group, 79.4% completed the intake survey and were included in the analytic sample for fidelity assessment. Fidelity was measured as coverage, content adherence and frequency of each core component, and the moderators assessed were implementation site and patient activation measure. RESULTS:Content adherence was high for three components with nearly 80.0% of patients setting ≥ 1 goal, having ≥ 1 PC visit and receiving ≥ 1 education session. Only 45.0% patients received ≥ 1 SDH referral. After adjusting for patient gender, language, race, ethnicity, and age, the implementation site moderated adherence to goal setting (77.4% BH vs. 87.7% VA), educational coaching (78.9% BH vs. 88.3% VA), number of successful CHW-patient encounters (6 BH vs 4 VA) and percent of patients receiving all four components (41.1% BH vs. 25.7% VA). CONCLUSIONS:The fidelity to the four CHORD intervention components differed between the two implementation sites, demonstrating the challenges in implementing complex evidence-based interventions in different settings. Our findings underscore the importance of measuring implementation fidelity in contextualizing the outcomes of randomized trials of complex multi-site behavioral interventions. TRIAL REGISTRATION:The trial was registered with ClinicalTrials.gov on 30/12/2016 and the registration number is NCT03006666 .
PMCID:10045092
PMID: 36978071
ISSN: 1471-2458
CID: 5454102

Policy by Pilot? Learning From Demonstration Projects for Integrated Care Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study"

Gore, Radhika
Analysis of policy implementation for chronic disease in Belgium highlights the difficulties of launching experiments for integrated care in a health system with fragmented governance. It also entreats us to consider the inherent challenges of piloting integrated care for chronic disease. Sociomedical characteristics of chronic disease -political, social, and economic aspects of improving outcomes - pose distinct problems for pilot projects, particularly because addressing health inequity requires collaboration across health and social sectors and a long-term, life-course perspective on health. Drawing on recent US experience with demonstration projects for health service delivery reform and on chronic disease research, I discuss constraints of and lessons from pilot projects. The policy learning from pilots lies beyond their technical evaluative yield. Pilot projects can evince political and social challenges to achieving integrated chronic disease care, and can illuminate overlooked perspectives, such as those of community-based organizations (CBOs), thereby potentially extending the terms of policy debate.
PMID: 35942955
ISSN: 2322-5939
CID: 5286802

Ensuring the ordinary: Politics and public service in municipal primary care in India

Gore, Radhika
This paper examines the political embeddedness of public-sector primary care in urban India. The low quality of urban healthcare in many low- and middle-income countries is well documented. But there is relatively little analysis showing how the politics of urban healthcare delivery contribute to quality shortfalls. This study integrates urban and political theory and draws on ethnographic fieldwork in municipal government-run primary care clinics in Pune, India. I conceptualize Pune's municipal doctors as street-level bureaucrats: frontline state agents charged with delivering public services, who regularly confront conflicts between their mandate and its realization in practice. I observe how the municipal doctors experience and respond to these conflicts; delineate the historical design of the municipal institutions in which they operate; and interview doctors, nurses, nonclinical staff, administrators, and elected officials, who collectively shape primary care delivery in municipal clinics. My findings show how the doctors' work is characterized by routine departures from public service ideals. The departures stem from local electoral politics (politicians' patronage and clientelistic relations with municipal employees and patients) and weak administrative capacity (misuse and incompetent planning of public resources). The doctors are compelled to follow extra-policy directives, meaning instructions that have little to do with healthcare goals and that emphasize the political utility rather than medical purpose of their work. In response, the doctors circumscribe their clinical practice. They aim, as one doctor put it, only to "ensure the ordinary," or to sustain a deficient status quo. In these conditions, improving quality of care requires not just behavioral interventions targeted at doctors. It requires normative, social, and organizational shifts in public service planning and delivery so that doctors are positioned - materially and affectively - to meet urban healthcare challenges in low-resource contexts.
PMID: 34265542
ISSN: 1873-5347
CID: 5265892

Implementation Fidelity of a Complex Behavioral Intervention to Prevent Diabetes Mellitus in Two Safety Net Patient-Centered Medical Homes in New York City [Meeting Abstract]

Gupta, Avni; Hu, Jiyuan; Huang, Shengnan; Diaz, Laura; Gore, Radhika; Islam, Nadia; Schwartz, Mark
ISI:000695816000049
ISSN: 0017-9124
CID: 5265982

Influence of organizational and social contexts on the implementation of culturally adapted hypertension control programs in Asian American-serving grocery stores, restaurants, and faith-based community sites: a qualitative study

Gore, Radhika; Patel, Shilpa; Choy, Catherine; Taher, Md; Garcia-Dia, Mary Joy; Singh, Hardayal; Kim, Sara; Mohaimin, Sadia; Dhar, Ritu; Naeem, Areeg; Kwon, Simona C; Islam, Nadia
Hypertension affects a third of U.S. adults and is especially high among Asian American groups. The Racial and Ethnic Approaches to Community Health for Asian AmeRicans (REACH FAR) project delivers culturally adapted, evidence-based hypertension-related programs to Bangladeshi, Filipino, Korean, and Asian Indian communities in New York and New Jersey through 26 sites: ethnic grocery stores, restaurants, and Muslim, Christian, and Sikh faith-based organizations. Knowledge of the implementation mechanisms of culturally adapted programs is limited and is critical to inform the design and execution of such programs by and in community sites. We applied four categories of the Consolidated Framework for Implementation Research-intervention and individuals' characteristics, inner and outer setting-to analyze factors influencing implementation outcomes, that is, site leaders' perceptions about adopting, adapting, and sustaining REACH FAR. We conducted semistructured interviews with 15 leaders, coded them for implementation outcomes, and recoded them to identify contextual factors. Our findings show that REACH FAR resonated in sites where leaders perceived unhealthy diet and lifestyles in their communities (intervention characteristics), sites had historically engaged in health programs as a public-service mission (inner setting), and leaders identified with this mission (individuals' characteristics). Site leaders strived to adapt programs to respond to community preferences (outer setting) without compromising core objectives (inner setting). Leaders noted that program sustainability could be impeded by staff and volunteer turnover (inner setting) but enhanced by reinforcing programs through community networks (outer setting). The findings suggest that to facilitate implementation of culturally adapted health behavior programs through community sites, interventions should reinforce sites' organizational commitments and social ties.
PMID: 31260065
ISSN: 1613-9860
CID: 3967852

Integrating Community Health Workers into Safety-Net Primary Care for Diabetes Prevention: Qualitative Analysis of Clinicians' Perspectives

Gore, Radhika; Brown, Ariel; Wong, Garseng; Sherman, Scott; Schwartz, Mark; Islam, Nadia
BACKGROUND:Evidence shows community health workers (CHWs) can effectively deliver proven behavior-change strategies to prevent type 2 diabetes mellitus (diabetes) and enhance preventive care efforts in primary care for minority and low-income populations. However, operational details to integrate CHWs into primary care practice remain less well known. OBJECTIVE:To examine clinicians' perceptions about working with CHWs for diabetes prevention in safety-net primary care. SETTING/METHODS:Clinicians are primary care physicians and nurses at two New York City safety-net hospitals participating in CHORD (Community Health Outreach to Reduce Diabetes). CHORD is a cluster-randomized trial testing a CHW intervention to prevent diabetes. DESIGN/METHODS:Guided by the Consolidated Framework for Implementation Research, we studied how features of the CHW model and organizational context of the primary care practices influenced clinicians' perspectives about the acceptability, appropriateness, and feasibility of a diabetes-prevention CHW program. Data were collected pre-intervention using semi-structured interviews (n = 18) and a 20-item survey (n = 54). APPROACH/METHODS:Both survey and interview questions covered clinicians' perspectives on diabetes prevention, attitudes and beliefs about CHWs' role, expectations in working with CHWs, and use of clinic- and community-based diabetes- prevention resources. Survey responses were descriptively analyzed. Interviews were coded using a mix of deductive and inductive approaches for thematic analysis. KEY RESULTS/RESULTS:Eighty-seven percent of survey respondents agreed CHWs could help in preventing diabetes; 83% reported interest in working with CHWs. Ninety-one percent were aware of clinic-based prevention resources; only 11% were aware of community resources. Clinicians supported CHWs' cultural competency and neighborhood reach, but expressed concerns about the adequacy of CHWs' training; public and professional emphasis on diabetes treatment over prevention; and added workload and communication with CHWs. CONCLUSIONS:Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs' effectiveness and operations is needed to overcome concerns about integrating CHWs in primary care.
PMID: 31848857
ISSN: 1525-1497
CID: 4243602

Implementing a multi-level electronic health record and community health worker intervention in immigrant-serving primary care practices to improve hypertension control among South Asian patients [Meeting Abstract]

Islam, Nadia; Gore, Radhika; Zanowiak, Jennifer; Wyatt, Laura; Mohaimin, Sadia; Lopez, Priscilla; Divney, Anna; Lim, Sahnah; Thorpe, Lorna
ISI:000533323500160
ISSN: 1748-5908
CID: 4508132

Changing Clinic-Community Social Ties in Immigrant-Serving Primary Care Practices in New York City: Social and Organizational Implications of the Affordable Care Act's Population-Health-Related Provisions

Gore, Radhika; Dhar, Ritu; Mohaimin, Sadia; Lopez, Priscilla M.; Divney, Anna A.; Zanowiak, Jennifer M.; Thorpe, Lorna E.; Islam, Nadia
ISI:000551501400012
ISSN: 2377-8253
CID: 5265952

Feasibility and Outcomes of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices

Lopez, Priscilla M; Divney, Anna; Goldfeld, Keith; Zanowiak, Jennifer; Gore, Radhika; Kumar, Rashi; Laughlin, Phoebe; Sanchez, Ronald; Beane, Susan; Trinh-Shevrin, Chau; Thorpe, Lorna; Islam, Nadia
BACKGROUND:South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease. OBJECTIVE:We report 12-month results of an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods. DESIGN/METHODS:Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility. MEASURES/METHODS:Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg. RESULTS:Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components. CONCLUSIONS:EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.
PMCID:6527132
PMID: 31095056
ISSN: 1537-1948
CID: 3903352