INNOVATIVE METHODS OF
ADDRESSING CARDIOVASCULAR
DISEASE AND DIABETES IN
ASIAN AMERICAN COMMUNITIES
NADIA ISLAM, PHD
HEALTHFIRST 2014 SPRING PROVIDER SYMPOSIUM
INNOVATIONS IN POPULATION HEALTH MANAGEMENT
MAY 16, 2014
The Problem
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Heart disease and stroke cause 1 of every 3 deaths
in the U.S.
67 million adults in the U.S. have hypertension and
57% of those individuals have uncontrolled status
25.8 million children and adults in the United
States—8.3% of the population—have diabetes
Diabetes and hypertension disparities
disproportionately impact racial and ethnic minority
communities
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Population Affected: Asian Americans
•AANHPI population is
projected to be 43.2
million in 2050 – or
10% of the entire U.S.
pop.
•Projected increase
between 2000 and
2050 in the population
of individuals of Asian
descent in the U.S. is
213% -- compared to a
49% percent increase
in overall pop.
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Top 10 Cities for Asian Americans
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Percent of U.S. adults age 18 and over with selected
conditions, by race and ethnicity, 2004-2006
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Diabetes and Hypertension in NYC
Asian Communities
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Age-adjusted rates of diabetes for Asians in NYC
13%; rates varied substantially among subgroups,
ranging from (Islam et al. Diabetes Care. 2013 Jan;36(1))
A mixed-methods study of Bangladeshi immigrants
in NYC found 25% of community members
surveyed reported diabetes. Cultural and
linguistic barriers to diabetes management were
also identified (Islam et al. American Journal of Public Health. 2012)
Community-based screenings in NYC reveal that
53% of Filipinos screened were hypertensive
(Ursua et al
Journal of Community Health 2013)
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Unique barriers to care and prevention
Asian Americans are less likely to report positive patient-physician interactions
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
The Commonwealth Fund. (2001). Health Care Quality
Survey
Innovation: Community Health Worker
Approach
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Burgeoning literature demonstrating CHW effectiveness across many
different conditions
Large workforce :11,000 in NYS; 120,000 nationally
Patient Protection and Affordable Care Act
 Several elements of the federal health reform law can be
facilitated through strong CHW participation
 Increase access – Improve quality – Lower costs
Patient-Centered Medical Homes, ACO, Health Homes
 CHWs play important role in coordinating care and helping
people manage care
Martinez J, Ro M, Villa NW, Powell W, Knickman JR. Transforming the Delivery of Care in the Post–Health Reform
Era: What Role Will Community Health Workers Play? Am J Public Health 2011;101(12):e1 – e5.
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
WHO ARE CHWs ?
CHWs are frontline public health
professionals who have an
unusually close understanding of
the communities they serve through
shared ethnicity, culture, language,
and life experiences.
Also referred to as …
Promotor-es/-as
Outreach Workers
Community Health Representatives
Patient Navigators
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
CHW Approaches

Improve access to health care
resources
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Improve the quality and cultural
appropriateness of service delivery
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Help others integrate disease
prevention and management into
their daily lives

Organize communities to improve
environmental, physical and social
wellbeing

Negotiate cultural & linguistic
barriers to health

Help others become active
participants in their own health
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
USAID, Community and Formal Health System Support
for Enhanced Community Health Worker
Performance Report, 2012
http://www.coregroup.org/storage/Program_Learning/Community_
Health_Workers/chw%20evidence%20summit%20final%20report19dec2012.pdf
Evaluating CHW Effectiveness in
Preventing and Managing Chronic Diseases
Across Asian-American Subgroups
Asian American Partnerships in
Diabetes Research, Education,
Research and Empowerment
and Action for Minorities
Reaching Immigrants through
Community Empowerment
Grant Type: R24
Grant Type: P60
Grant Type: PRC
Funder:
NIMHD
Funder:
NIMHD
Funder:
CDC
Duration:
8 Years
Duration:
5 Years
Duration:
5 Years
Overall Goal:
Overall Goal:
Overall Goal:
To improve health care access
and CVD status in the NYC
Filipino American
community through a CHW
intervention
To develop, implement and test
a CHW program designed
to improve diabetes
control and management
in the Bangladeshi
community in NYC.
To develop, implement, and test
a CHW program designed
to promote diabetes
prevention among Korean
and South Asian
Americans in NYC
Asian American Partnerships in
Diabetes Research, Education,
Research and Empowerment
and Action for Minorities
Intervention Duration: 4 mos.
Intervention Duration: 6 mos.
Intervention Duration: 6 mos.
Design:
Design:
Design:
RCT
RCT
Reaching Immigrants through
Community Empowerment
RCT
(Treatment &
(Treatment &
(Treatment &
Control arms)
Control arms)
Control arms)
Components: (Treatment)
Components: (Treatment)
Components: (Treatment)
4 Education Sessions
5 Education Sessions
6 Education Sessions
4 Follow-Up Visits
2 Follow-Up Visits
10 Follow-Up Phone Calls
8 Follow-Up Phone Calls
Phone Calls as needed
Asian American Partnerships in
Diabetes Research, Education,
Research and Empowerment
and Action for Minorities
Korean Community:
… modest reductions in mean weight,
BMI, Systolic BP (NS)
Blood Pressure Change
(Implementation Phase)
More Intensive
Intervention
(n=62)
Less Intensive
Intervention
(n=78)
-27.0 mmHg
Systolic
-9.2 mmHg
Systolic
-10.9mmHg
Diastolic
-3.5 mmHg
Diastolic
Measured from Baseline to
8 month follow-up. The
differences in the means
were significant at p<0.001
Reaching Immigrants through
Community Empowerment
… significant reductions in mean
weight & BMI (p<.0.05)
… significant improvements in:
(p<0.05 – 0.001)
• self-reported physical activity
• food-related behaviors
• diabetic management knowledge
• self-efficacy
… significant increases in:
• PA self-efficacy (p<0.10)
• eating brown rice (p<0.05)
Sikh Community:
… significant reductions in mean
weight, BMI, glucose, BP (p<0.10)
… significant increases in: (p<0.05)
• physical activity & self efficacy
• fruit consumption
• food purchasing self-efficacy
… significant reductions in soda
consumption (p<0.05)
Lessons Learned
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Very few culturally/linguistically
appropriate materials available
for these communities
Balancing scientific rigor with
what is culturally acceptable in
community
Challenges associated with
reaching/retaining individuals
immigrant communities
Justifying role of CHWs to other
healthcare providers: need for
better integration of CHWs into
clinical systems
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Next Steps
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New York University- City University of New York Prevention Research
Center (NYU-CUNY PRC) to be funded by the CDC in Sept 2014
NYU-CUNY PRC Overall Goal: The NYU-CUNY PRC goals are centered on
advancing the study of innovative combinations of community health worker
(CHW) and electronic health record (EHR)-based interventions for
cardiovascular disease (CVD) management and prevention for three key
reasons
To achieve these goals, the NYU-CUNY PRC has expanded and
strengthened its stakeholder network to include community health providers,
healthcare delivery systems, and health plans that are prepared and
committed to partner with us
Key partner: Healthfirst
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Project IMPACT
(Implementing Million Hearts for Provider and
Community Transformation)
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Leveraging CDC’s Million Hearts ® Initiative
Project IMPACT will examine the efficacy,
adoption, and impact of integrated EHR-based
decision-support and physician feedback
interventions with CHW-led self-management and
coaching support for South Asian patients with
uncontrolled hypertension
Study Timeline: September 2014 – September
2019
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Study Aims
 Determine unique risk factors and develop a culturally-specific
CVD risk factor profile for South Asian patients with
uncontrolled hypertension.
 Develop and implement EHR-based decision-support and
performance feedback interventions designed to support
physicians in managing risk factors related to hypertension and
diabetes control and CVD prevention for South Asian patients.
Community
Groups
 Implement and assess the efficacy of linking CHWs and EHRbased physician decision support systems within health care
systems.
 Develop and disseminate a set of best practice
recommendations on integrating EHR and CHW initiatives to
advance Million Hearts goals to public health agencies, insurer
organizations, and physician practices.
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Payer
Organization
CHWs
+
EHR / HIT
Health
Systems &
Providers
Conclusions
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CHWs provide a critical link between
communities and health systems and can
help to improve health behaviors,
diabetes knowledge & management, &
self-efficacy for vulnerable pouplations
Community-engaged, tailored approach
Integration of CHWs into healthcare
teams and fostering their acceptance by
providers and systems will be essential to
their effectiveness
Cotinual, comprehensive, and rigorous
evaluation is essential to advancing the
effectiveness of the CHW model
Acknowledgments
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CHWs & Staff
Community Partners & Coalitions
Study Co-Authors
This presentation was made possible by Grant Numbers 2P60MD000538-05,
U48DP001904, and its contents are solely the responsibility of the authors and
do not necessarily represent the official views of the NIMHD or CDC. Also
supported in part by the NYU CTSA grant UL1TR000038 from the National
Center for Advancing Translational Sciences (NCATS), NIH.
Healthfirst 2014 Spring Provider Symposium
Innovations in Population Health Management
Contact Information:
Nadia Islam, PhD
NYU School of Medicine
Tel No 212-263-7075
Email [email protected]