Today we talk with Dr. Elizabeth Vaughan, associate professor and physician scientist at the University of Texas Medical Branch, as well as a Texas Community Health Worker instructor, about her research in health disparities and the role of the Community Health Worker in improving diabetes outcomes in low-income populations.
Doctor Elizabeth Vaughan welcome to the move to value podcast
Thanks so much for having me, it’s a pleasure to be here.
So, tell me Dr. Vaughan, how did you become interested in researching the impact of community health workers?
Like many things in life, I fell into the interest. I had done the international work since I was in high school and I always had an interest of low-income healthcare, low-income populations. As a 16 year old I went to Ecuador and you know I was a what you call an army brat, my father was in the army, and really a pretty isolated world. And I saw poverty like I had never seen. I realized that Spanish was not just punishment that I had to take in high school that other people were really speaking Spanish and I really fell in love with the people in Ecuador. And then I continued traveling and you know fast forward that 20-30 years now and I’ve gone most of Central America, South America, and the Caribbean over and then over to Africa and India. And through those travels the people that I worked with were precious and yet I always sensed a distance between the people I worked with and me. And particularly after I finished medical school and I was now doctor Elizabeth or doctor Vaughan, most countries it was doctor Elizabeth, there was a greater separation. So there was a socioeconomic separation there was a cultural separation there was an education separation. And yet I saw the locals and the way they interacted with local individuals, and I thought there’s something different here, they seem to be able to reach these individuals.
Then when I was in India in 2011 I worked with a group of promotoras, or more referred to as community health workers, in India and I anticipated that I would be the physician going into the villages and the towns and I quickly realized that they wouldn’t let me because it was the HIV trip. And so I stayed back in the in the clinic and I taught this group of promotoras. And I at first was disappointed thinking man I don’t get to have the fun only to be on the front lines and yet I quickly saw that teaching blood pressure, teaching hydration, teaching triage, led into a world where they could triage patients appropriately and they could reach far more patients than I could ever reach as an individual person. And so then I realized this is something and so fast forward another ten years and I became a community health worker instructor myself, started working and founded some groups here in Houston, TX of promotoras and have just seen amazing work of what they do and how they are able to connect with the patient and bring things about from a patient that I never could bring out and offer insight that I would never have.
Tell me why, in your opinion, do you feel like folks respond to other individuals in their community more than they would someone who’s a physician. Someone who comes in with the technology and the knowledge from first world country. Why do you feel like there is a barrier there to the to the general population who needs those services?
It’s a great question. So, there’s, different cultures have different barriers. I think in the Latino culture pleasing in and kind of letting the doctor know that that you’re trying to do what they said, I think is important. I think there’s a there’s amount of respect, they say you’re the doctor you’re and help me and so if they don’t, I think there is some sometimes there’s a feeling of shame in there. And so, my experience with the Latino culture is, many times the reason they don’t – I’ve had one patient in you know 13-15 years of practice that just had the medications on the desk would not take them. Not to say there aren’t others but, you know, most reasons that they don’t take medications, they don’t adhere to treatment, are far beyond what I would ever understand, or that they might be willing to tell me and it might be embarrassing.
We had a patient that we could not figure out why she would not apply for eligibility of the clinic, you know it’s free service we thought we you know the community health workers were helping her and taking and what’s going on with this? And finally we, the community health worker not me, learned that she was in an abusive relationship and that the husband would not let her have her tax papers, and that’s what she needed to prove income status at the clinic to prove that she was eligible for the low income clinic. And she never wanted me to know that she wanted me to know that she’s trying her hardest to do what I asked her to do and she really wants her diabetes to get better and her health to get better. It’s embarrassing and maybe they know deep down the side I will never understand what life looks like in a in another world. And truly there’s a world I’ll never understand what it means to be undocumented. I will understand what it means to not speak English as my first language. I will understand what it means not have transportation to get to the clinic when I need to do so.
So, there’s a variety of barriers but I think just wanting to do what the doctor wants to do I think that’s a major barrier that that they that they face that they may feel much more comfortable talking to a community health worker who they trust who might have the same barriers and often have the same barriers as they have.
Sometimes we forget the barriers we often think about are you know literacy, transportation you know language barriers, but we often forget about some of the barriers that are much more challenging like clinic eligibility, like medication eligibility. For instance we have medication programs called PAP, prescription assistant programs, and on paper they’re great. But I am not the first investigator to say that there’s a lot of holes in the system. What these are, it’s a way to get these expensive meds, so out of the 11 oral diabetes meds, three of them are low cost. And so how do you get the other eight to them? So some of them are eligible through this process, but every med has a different process. Sometimes you apply and you might wait a month or two or six or nine months to actually get the med and then you have to reapply after the next year. And so you know put yourself in the shoes of someone who doesn’t speak English, who may not use the Internet, who doesn’t understand all this paperwork, and didn’t even know that after all of this, they have to renew every year. And so just imagine how, and that’s one pill of the maybe five or six that you’re taking and maybe you have to do this for every different pill.
And so barriers like that are things we often forget about and we say oh you know patients can just they can take these meds you got them they’re available there’s a supply, and it’s like well put you know once you kind of walk that path, and I never walked it. I prescribe it was easy and then I realized when the promotoras brought it to my attention, well they did this this and this and they’re having XYZ barrier, I realized oh my goodness. There are numerous barriers to this system. Once it works it’s great, but getting there and getting it to be sustainable it is markedly extremely challenging.
So, tell me how community health workers go about effectively educating and triaging members of their community?
Well the first way for them to educate, is they have to be educated themselves and they have to have some sort of foundation of their own training. Every state is different, some states have very rigorous programs, training certifications, recertifications, some states do not, but nationally, there are national standards. And so that’s one thing that is ongoing in legislation, so we’ve got to make national standards for this if we’re going to really get these individuals on the you know on the line items of a budget.
So first it is you know what other certifications so what does it mean to be CHW? First place, if I say I’m a physician, you have a pretty good idea of what training I’ve done. For a CHW it’s a little more nebulous. So the first after the second after their education is educating actually what they’re doing. So, I learned what a CHW is in my certification process, but I don’t know what HIPAA is, I don’t know what PHI is, I don’t know what telehealth is, or telemedicine is. I have to learn all of these terms. I’m not medical. I’ve never stepped foot in the hospital before unless it was for my own care, and so they need to be educated in the realms where they’re going to practice.
Then they need to be educated in triage. In other words, someone calls them, my blood pressure is 230 / 110 and if they say, what do those numbers mean, we have some problems. We had a patient you know they often call the community health workers first. They’re trusted individuals of the community by definition and you know by definition this this person called they didn’t call their doctor they call the ER and they said I’m having this left sided facial numbness. And thankfully we had taught our community health workers what triage means, education, and you know when you know when you call and when you don’t and so thankfully the community health worker knew what to do, direct the person to the ER, they were able to get this person the appropriate treatment before they had long term sequelae of what we now know was a stroke. But if a community health worker doesn’t understand what blood pressure is or what normal numbers are, and we tell them you know make sure they check, make sure they recheck, we tell them how they check, they’re not doctors, and they know that. There’s a very very, but they have to understand how to get a history so they can help the patient.
So if I were to frame that entire question that you asked, how do we effectively educate and triage it comes back to the education. It comes back to educating them appropriately and then supporting them. When they have a question when they’re out in the field who do they call? Who do they get help from? If it’s a you know Tuesday night at 8:00 PM, do they have a way to get, someone a lot of times that’s when they work with the patients because that’s in the patients aren’t working, and is there a mechanism if not we worry about them doing harm because there’s no mechanism of help and support.
That leads into my next question of how do we go about verifying that these CHW’s are going to do more good than harm for the patient. I realize, you know, and we think we all realize, that there’s definitely a good intent and a willingness to care, but you know when you start to jump into cultural norms that might not always be the best policy for healthcare, how do we how do we go about verifying that that the information is accurate that they’re providing?
Yeah so doing harm you know relates to the question we talked to before, making sure they’re perfectly trained, make sure they have the appropriate education and support. I think that that key piece, a lot of times I’ll see in programs they’re trained. Maybe it’s a one-time training, maybe it’s a two-time training, oh we we’ve got them certified, we’ve got them but there’s no ongoing support. You know when I did residency you know that’s you know 3-4 years of you’re in the hospital and you know you have this system of you know the duck and the ducklings to make sure that you weren’t going to harm patients. And so I knew whenever I got in the spot where I wasn’t comfortable I always knew I had someone to call, 24/7, and that’s critical to do no harm. I’ve seen situations in medical training where residents don’t have someone to call, and that’s what harm is done. Because they don’t they don’t know who the call they don’t know who to ask and there’s fear there. And so the same principle with community health workers.
The training that we have we have a website now, mipromothorasalud.org, and we’ve posted our trainings on it and we’re just kind of getting all four segments on it. So, in the first training we have an introduction. this is OK what does this mean, community health worker 101. It’s like a four-hour course and this is all your HIPAA and PHI, what does it mean to be CHW, what does it mean in the specific place I’m working. You know, beyond where’s the bathroom, how do I how do I work what are the kind of the rules of the land in where I’m working. The second and third training are the immersion. So for us we work in diabetes. So, the first part is we got to learn about what diabetes is. What’s an A1C? What’s a blood pressure? We got to learn all about that, so just the really concrete knowledge. Then that we take it after that, once they’re actually working with patients, then we have in an immersion training on what are all the medications, what are the side effects, because you know they’re going to be calling them and saying my legs are swollen, and if we don’t know if they don’t know the Actos can cause that swelling, and the patient was just put on Actos, we’ve got a problem.
And so they need to understand what the patients are going, just like if you’re in the in the visit with your doctor and your family member. A lot of times they tell the family member, particularly if the family member is older or needs some help, they tell the family member to make sure you know this and this. Now the family member, it typically goes over their heads. But a lot like that the community health worker almost acts like a family member.
And then the last part of it is the sustainability and so we take questions that community health workers have asked us over the years and we just answer them in the last training. You know what about what why do I take a statin, these silly rules that keep changing, I don’t understand, my LDL’s right, it’s 90, I thought they had to be less than 100, well yeah we changed the rules again on you. So you know explaining that so when the patients asking that, they know very clearly they do not make the decisions, they are not medical decision makers, they take a history and then they triage appropriately to the to the appropriate person.
That makes a lot of sense. So let’s talk about you for a moment. I’d like to hear more about your research with diabetes and underserved patients and how you’ve used the time model and the simple model and how they differ and perhaps which is more effective.
Sure, so the TIME model is an acronym telehealth integrated community health workers medication access and education and group visits. And so if you were to simplify what is this model, it is a group visit so patients come to the clinic once a month for their care and they see a physician and they have education, everything is run by community health worker, the large group education, the small group education, they run monthly for six months, and now we actually have a model extends to a month nine and month 12, because we get to six months and we said we’re not quite there yet. So we kept it kept going a little longer. And that model is very much you have almost the cream of the crop patients and so it’s hard to compare it to our other model which is a SIMPLE model the simple model is OK take everything in TIME, you basically make TIME really simple.
So in SIMPLE instead of physically coming to the clinic for the group visit education or small group, they sit on a YouTube modality for about you know 5 to 15 minute videos and then you have the community health worker and instead of them physically sitting down they call them up and ask them how they how they’re doing. In both of those models we have what’s called a feedback loop because inevitably they will see the doctor or they will talk to the doctor in clinic on one day and the next day they call the community health worker and say I don’t have my pills and you just saw the doctor well I don’t know. And so there’s some sort of communication gap that happened there, and it happens even though they just saw them. And so that feedback loop goes from the community health worker and there’s a champion but then feeds into the clinic who has a champion and say hey patient so and so doesn’t have their you know ACE inhibitor and now we need to you know what happened, oh I thought we were supposed to put this at Walgreens we called them into the wrong place. So, you know a lot of times it’s just an easy communication gap and that feeds back to the community health worker and they can tell the patient. What usually happens is, I don’t have my pills, I call the clinic, I get voicemail, they call the patient, the patient’s phone has been disconnected, they don’t have enough data, so they wait for three months to get an appointment, have high blood sugar the entire time, finally go see the doctor and hope it gets right this time, if not then wait another three months, and the same cycle continues. And you know we see in in in this population the A1C’s or the other glucose levels they go up and down and up and down and up and down from really controlled to really bad really and I thought why in the world is that and I did a study one time I just looked at patient notes and I thought oh that makes sense they’re on their meds off their meds on their meds off their meds. And a lot of times the gap is, like we talked about before, the medication eligibility process or it’s also just communication gaps that they have.
So what’s better between the two of them, it’s hard to compare because they’re a little bit apples and oranges where the TIME these are patients who are motivated to come to clinic and they typically have transportation to get to clinic, they have more resources, typically. We see an A1C drop you know .5 is considered significant we see drop typically of two to 2 ½. In the SIMPLE model we still lower drop. These are patients though that’s more of a kind of opt out, like hey we’re running this program if you don’t want to join it no need to and then I’m sure I’ll do it. So these are not your cream of the crop patients. These are the patients that are what if they can’t come to clinic, what if they don’t want to do group visit, how do we reach the people who are maybe less motivated or don’t have transportation or work a lot. So these A1C drops are typically one 1-1 ½, still clinically significant and still a nice drop. And the good thing about the SIMPLE models is it is much more scalable, because it’s not an intense monthly come to the clinic, you can run it with 2-3-4 times the amount of people that you could run in the TIME model. So both of them are good models. I don’t have a bias I like them both. I think they’re both great for but it really depends on the clinic situation and depends on the patient situation, but SIMPLE was named simple for the reason, it’s simple.
With this patient population, how has deploying community health workers on the frontline changed outcomes?
There’s a lot of literature out there about changing diabetes outcomes and there’s a many many interventions, you know, educational interventions, medication interventions, and so I thought, you know, what CHW, what’s different, you know, why have ACH in in this this part, when there’s other literature that shows we could do other things. And you know we don’t compare these arms, typically we typically have different studies, so it’s hard to compare them. In looking back at some of the things that we’ve done, the community health workers really enable whole person care and a lot of the diabetes studies are done on a 24 week period, so they’re six month studies and both you and I know diabetes doesn’t end in six months. It’s a disease of a lifetime and if we don’t solve or work on whole person care, we’re not going to have anything that’s sustainable. So what CHWs enable and help with is our sustainable care. In other words, I can’t cut my head off from my body. If I have anxiety and I have depression, I’m not really motivated to take my pills. On the flip side if I am overweight, obese, and I am always tired, I don’t feel good, so mental health takes – and so you can’t disconnect them. So the way your body is physically affects you mentally, the way you are mentally affects you physically, and CHW’s are really able to dive into the emotional barriers, the mental health barriers that often we don’t have time to in clinic, or we just don’t have their trust and relationships that we including clinic.
You know I was in a in Detroit, I love Detroit, a while back and there was a free clinic and there was a physician, he said I just don’t understand it we give them free pills and the patients have free care and they still don’t take their pills. Well, I knew that area of Detroit he was working in because I worked there myself doing some volunteer work. It was a very dangerous area of Detroit, and I said you know they recently took they recently took their streetlights out. So, you walk home everything’s in the dark the most dangerous area, one of the most dangerous areas in Detroit. If you’re thinking about someone chasing you with a knife and if you’re going to make it home alive, you’re probably not thinking did I take my metformin today. And so if we’re not addressing some of these social economic barriers and safety barriers and just key things that we need to be a human being, patients don’t really think a whole lot about their healthcare. So that’s a key element is, do you feel safe, do you feel secure, do you have trust, do you have worries, are you sad, and those are key things to us being like, OK now I want to take care of myself, I’m going to live healthier, I’m going to do what I need to do to have a healthy life.
One final question. You know CHESS does, we are in the value-based care space and that’s where we live that’s where we work and we’ve we’re always trying to figure out solutions to problems that’s going to alleviate all kinds of stressors on the provider, the care team, we’re trying to make a really a wellness centered community, so how do you see the role of the community health worker enhancing value based care?
So, value-based care in my mind is centered around quality more than quantity, if I were to take a stab at a very low-level definition of it. And CHWs that’s like the definition. That’s what they do, they are quality. You know, they offer insights to barriers, they enhance communication, they provide clarification. You know a lot of medicine is really straightforward. Don’t get me wrong, medical school wasn’t a walk in the park, but yeah I tell some of the residents and trainees, you know, I said you can have a brilliant plan, a scientific plan you know that’s just amazing and why they’re taking this and physiologically why it works in their body and you know. But if they don’t take it, your plan is worthless. Doesn’t do a thing and a lot of times in medicine, particularly in primary care, particularly in our chronic disease management, we have great plans and really smart people making really really good plans, but if that plan is not implemented successfully and sustainably, and the patient it hasn’t helped the patient, and it hasn’t helped the healthcare system as a whole, And so community health workers are able to be almost like, one of the slides I show them when I’m teaching them you know and find I always recruit a group of people and tell them what a CHW is, I have a picture of a spy and a detective. I say you’re detectives, you figure out what’s going on, you dig deep, you ask, you learn, and you do it in a loving kind compassionate way, because you may be facing those barriers too. You may get it. And that I think is the is the critical point of what community health workers do.
You know we talked about the PAP, our PAP medications earlier, and then we had a patient that came to us that her sugar was 400. Oh my goodness and we just seen her and she said you know the community health worker called, Oh my gosh she’s 400 and apparently the police were at the house then all sorts of social stuff going on so she was able to give us insight of what was going on and why she was taking the meds, and she just told the doctor a few days before that, sure I’ll take my insulin, sure that’s you know, I’ll get it, but she didn’t tell the doctor I can’t afford the insulin. Again, that gap, I don’t want to tell them. I’m embarrassed. I know you’re giving me a cheap $25 insulin at Walmart, and I still can’t even afford that, and I’m embarrassed about that. So, she said OK take the prescription then left. Well she calls the community health worker because she trusts them and the community health worker, through the feedback loop, reported it to the clinic and the clinic said well we’ve had insulin sitting here for months for this patient and she has a come and picked it up. It’s the expensive insulin, Lantus. I don’t know why I’ve been trying to call her and call her she won’t answer the phone. Back to the CHW oh I guess she has ran out of minutes, didn’t have data, tells the patient. So that patient’s A1C controlled A1C is less than seven she started the program around 12 or 13, she’s about 6.5 now, and it was just getting her on her meds. It wasn’t it’s not rocket science.
So you look at you know how does that help value based care? Well my goodness, that’s communication, you know? But it’s also trust and it’s perseverance and they offer all of that many individuals can’t offer on the medical team because they just don’t have the insight, and sometimes the patients, to offer that to the individuals. You know one thing that and I say probably the most important thing that I read over and over and over again with community health workers is sustainability. How do we get these programs? You know back in the 60s there is an act that allowed CHWs to be part of grants and everything else and I and I thought Oh my Goodness that was in 1962 and still one of the primary ways that we’re funding these community health worker programs is from 1962. That’s a long time ago and we haven’t made a huge amount of change and I’ve realized in these programs because that’s how I fund the community health workers how do we turn this into being a line item? You know I need in my clinic or I’m starting the clinic I need doctors I need nurses I need social workers I need therapists I need community health workers, that’s part of the medical treatment team. And I hope that we’re able to shift that vision in the US. I hope we’re able to agree upon national standards of community health workers and so we can move forward, OK, define them to we define them as hard to move forward with the standard, define it, standardize, and put them on as part of the healthcare team.
Medicaid and now there’s 29 of 48 states that have that Medicaid that utilize Medicaid funding for incorporating community health workers and so that’s a big step. Medicare also moving forward to include community health workers. Geriatric care is a great area to include incorporate community health workers, communication gaps that we’ve discussed during the podcast here. Uninsured individuals how do we do that? Individuals who don’t have Medicaid it’s a whole other podcast but you know thinking through how do we make these programs sustainable how do we keep these individuals who are extremely valuable who take a burden off an individual patient but also a large burden off the healthcare system? How do we keep them, how do we keep them around, how do we stop doing this I’m going to train you for three years and then you have to go start all over again with the next grant. I’m going to train you for five years start all over how do we stop that cycle that we’ve been doing since the 60s?
And so that’s my hope is that is that we’ll keep moving I hope that the that individuals continue to be aware of the value of community health workers and certainly the cost effectiveness of community health workers I hope that message is expanded I hope others are aware and we can keep this going and making it a sustainable resource in our healthcare systems.
Well, we certainly will help you spread that message loud and clear.
I appreciate that.
Dr. Elizabeth Vaughan, thank you for joining us today on the Move to Value Podcast.
Thanks so much it’s been a pleasure.