North Carolina has one of the country’s highest rates of diabetes. Community health workers could be key in reducing that rate by helping educate people at risk for the disease.
By Jasmin Singh
As she watched her father bring fresh produce to her community after the only grocery store closed, L’Tanya Gilchrist said she learned the importance of doing work in her own community.
“I remember my daddy on his truck going around in the neighborhood, selling fruits and vegetables to people,” said Gilchrist, a community-health assistant for the Durham Diabetes Coalition, run through the Durham County Public Health Department.
But then diabetes took Gilchrist’s father’s hands and legs, and eventually his life. Gilchrist became determined to get more involved with community efforts to reduce poverty and diabetes.
“Our main goal is to help patients become independent, and assisting them with understanding the disease itself,” she said. “They can live through it and overcome those barriers that they have.”
Gilchrist shared her story earlier this month at a diabetes forum organized by the Providing Access to Healthy Solutions program, an initiative led by the Harvard Law School’s Center for Health Law and Policy Innovation to highlight the importance of community-health workers and their role in diabetes prevention and management.
The center sponsored two Triangle-area forums, one in Raleigh and the other in Cary.
The PATHS program has looked at both New Jersey and North Carolina as states in which to potentially pilot several policy solutions that could eventually be scaled up to the federal level.
“There’s a lot of great work going on here in terms of moving the needle forward on diabetes prevention,” said Maggie Morgan, a health law and policy fellow at Harvard Law School who works with PATHS.
In 2010, some 688,000 North Carolinians received a diabetes diagnosis, and the percentage of adults in North Carolina with diabetes more than doubled in 15 years, from 4.6 percent in 1995 to 9.3 percent in 2010, according to PATHS.
Leading cause of death
Morgan said diabetes was the seventh-leading cause of death in North Carolina in 2012, but that it doesn’t affect everyone equally.
“For African-Americans, it is actually the fourth-leading cause of death,” Morgan said, “and for American Indians, it was the third cause of death.
“It’s a huge-disparity problem.”
Around 14.5 percent of Africa-Americans and 19 percent of American Indians reported a diabetes diagnosis in 2012, compared to 9.7 percent of whites, according to PATHS.
But Morgan said the state is unique in that it provides reimbursement programs for diabetes self-management education through Medicaid. North Carolina also reimburses for medical nutrition therapy, that allows diabetes patients to meet with a registered dietician to discuss what food will help them stay healthier. Both of these services are optional under federal Medicaid rules, but North Carolina has chosen to cover them.
But North Carolina Medicaid doesn’t reimburse for diabetes prevention, which can help someone who’s been diagnosed with pre-diabetes to keep from developing the full blown disease.
It costs the state money to fund prevention and management programs, but down the road, Morgan said, it would save the state money because fewer people will end up with health problems due to diabetes.
“They might as well stop it in its tracks before it starts,” she said.
Limited access to care
Morgan said another issue is the lack of health care providers who can provide diabetes management, especially in rural areas in the state.
But North Carolina is working to change this and community-health workers, like Gilchrist, have helped to slow the growing problem.
Jeffrey Katula, an associate professor of health and exercise science at Wake Forest University, said community health workers are key.
“They’re where the rubber meets the road,” he said. “They would know best what the needs of the group were.”
“We want to see patients live a better life,” Gilchrist said. “We help them achieve those positive goals that will help move them toward taking care of themselves.”
Katula said that by empowering community-health workers, they in turn empower their patients, “and county health departments can be feasible, powerful channels for diabetes-prevention programs.”
Among the supporters of these programs are local YMCAs, whose programs target the pre-diabetic population. Approximately 25 percent of people with pre-diabetes are expected to develop the disease within three to five years.
“YMCAs have really kind of moved the needle and are able to attract the population that needs it the most,” said Megan Merritt, associate executive director of the Corpening Memorial YMCA in Marion, the county seat of McDowell County.
“We know that those that are low income or have educational gaps do not necessarily always feel like they have access” to prevention programs, Merritt said.
Morgan said diabetes-prevention programs such as the one at the Marion YMCA is a great example of how the state could save money.
“They had 181 patients, and they expected 105 would avoid developing diabetes,” she said. “This would result in an estimated savings of over $1.2 million for each year that this group of patients did not develop diabetes, and that is just in that region.”
Gilchrist said her main goal is to make sure her patients in Durham are connected to their providers.
“We want to help those patients to find the confidence to sit down with their provider and ask those questions that they feel like they don’t have time to ask them when they are in the office at a particular visit,” she said.
Gilchrist said giving patients extra support, like phone calls and visits, not only helps them understand the disease better but also gives them a strong support system.
“We break down what type 2 diabetes really is. If they have questions, we stop and try to answer all of their questions. We take the time to sit down with them and write out their medications and what they are, what they do,” she said.
“It’s a lot, but we love it.”