Promotoras help diabetics overcome cultural, social and economic barriers

New findings from a 15-year series of studies led by care providers at Scripps Whittier Diabetes Institute reveal that culturally tailored community-created programs are effective at reducing health-related costs and delivering higher quality care.

Results from "Community-Created Programs: Can They Be the Basis of Innovative Transformations in Our Health Care Practice?" were published in the fall issue of Clinical Diabetes, and also posted on its website. The journal article discusses the results of a series of studies involving approximately 18,000 patients who were involved in Project Dulce, a culturally appropriate, clinically sound and cost-effective care model for managing diabetes.

"Since its inception 15 years ago, we have found that the Project Dulce model has demonstrated positive effects on physiological, behavioral and cost-effectiveness outcomes," said Athena Philis-Tsimikas, MD, lead author and corporate vice president, Scripps Whittier Diabetes Institute. "As the United States continues to seek methods to deliver higher quality medical care at lower costs, the concepts tested with Project Dulce in a real-world environment may prove particularly valuable."

Project Dulce Model

Project Dulce was developed in 1997 as part of a collaborative effort in San Diego County to improve the health and access to health care of under-served, ethnically diverse people with diabetes. Program partners include the Scripps Whittier Diabetes Institute, the County of San Diego, Community Health Centers and San Diego State University.

Since its inception, Project Dulce has enrolled and treated more than 18,000 patients - 65 percent of whom are of Latino/Hispanic descent - in 15 locations in San Diego.

The Project Dulce model uses a patient registry to identify and stratify patients with diabetes by risk. Trained diabetes registered nurses follow evidence-based care management protocols to lead a multidisciplinary care team that provides clinical care and management for patients in federally qualified community health centers throughout San Diego County. The team also includes registered dietitians and medical assistants acting as health coaches.

Trained peer educators-individuals with diabetes who have successfully managed their own disease-provide education and support to participants. These peer educators, or "promotoras," hail from the patients' ethnic group and are able to help patients overcome cultural, social, and economic barriers.

"We have found that using promotoras versus standard care is a much more successful method of delivering self-management education. Patients show better glucose control and improved outcomes in their diet and exercise," said Dr. Philis-Tsimikas. "The value of the promotoras stems from their direct experience with the community and firsthand understanding of the myths, beliefs and cultural remedies that may interfere with adherence to health recommendations. This type of support and empathy is often difficult for professionally trained individuals from outside the community to provide."

Project Dulce Results

In multiple comparisons of total costs, the Project Dulce diabetes care management program was associated with improved objective and subjective outcomes, including improvements in health status and quality of life, such as a decreased incidence of diabetes-related complications and hospitalizations throughout a patient's lifetime. Project Dulce achieved these results across a broad range of insurers and government programs, and was especially cost-effective for under- and uninsured groups.

Whereas costs for pharmacy, diabetes-related supplies and disease management increased under Project Dulce, hospital and emergency department care costs declined. This decrease in hospital and acute-care costs was attributable to a reduced likelihood of admission rather than lowered costs once patients were hospitalized, suggesting a clinically and economically meaningful benefit for a high-risk population.

For example, in 2009, as part of a statewide Health Care Coverage Initiative, a comparison of costs demonstrated that annual inpatient costs were $1,260 lower, and outpatient costs were $723 higher among participants in disease management program.

Tools for Chronic Disease Management

In addition to helping patients, Project Dulce staff is training other health care providers how to design and implement a culturally appropriate diabetes management program. To date, the program has been adopted by health care providers in New Jersey, Los Angeles and across the border in Tijuana, Mexico.

"The potential significance of this approach and these outcomes extends far beyond the borders of San Diego County," said Dr. Philis-Tsimikas. "Economical, effective and culturally tailored interventions such as the Project Dulce model may be a crucial link in our health care delivery system to achieve improved outcomes, not just for diabetes, but for many other chronic disease states."

Source: Scripps Health