M. Christina Esperat, PhD, RN FAAN
Debra Flores, MHRM
Linda McMurry, DNP, RN
Du Feng, PhD
Huaxin Song, PhD
Lynda Billings, PhD
Yondell Masten, PhD, RN, WHNP
Increased cost of chronic illnesses in United States is an urgent call to develop a cost effective approach to improve chronic disease self-management, especially among vulnerable populations. An emerging role for professionals and paraprofessionals is the patient navigator. We present an example of a conceptual framework, Transformation for Health, developed to underpin the training of certified community health workers (CHW) to deliver health care, preventive services, and health education for underserved populations to promote chronic disease self-management. Transformacion Para Salud (TPS), a patient navigation model for chronic disease self-management, was a two year demonstration program to develop a culturally sensitive intervention to facilitate patient behavior changes. Patients involved in the TPS intervention showed improvements in clinical and behavioral outcomes after twelve months of intervention. This article describes the conceptual basis and implementation of the TPS and discusses program evaluation, specific intervention outcomes, and implications for practice. Use of CHWs in the patient navigator role demonstrated a cost effective method to improve access to quality, cost-effective, primary health care services as well as to facilitate chronic disease self-management.
Citation: Esperat, M. C., Flores, D., McMurry, L., Feng, D., Song, H., Billings, L., Masten, Y., (May 31, 2012) "Transformacion Para Salud: A Patient Navigation Model for Chronic Disease Self-Management" OJIN: The Online Journal of Issues in Nursing Vol. 17, No. 2, Manuscript 2.
Key words: chronic care model, chronic disease self-management, community health worker, transformation for health, Transformacion Para Salud
The Transformacion Para Salud (TPS) experience describes a new paradigm to facilitate behavior change among people with chronic diseases though use of a trained patient navigator. This model can accommodate ideas and concepts from other existing theories of behavior. Behavior change among people suffering from chronic disease is needed so that they can effectively manage their condition(s).
The impact of this transformation can be inferred in economic terms. The United States spent $2.1 trillion on health care in 2006, an amount that represents 16% of the nation’s the gross domestic product. Much of the $2.1 trillion dollars spent was on chronic diseases since 133 million people, almost half of all Americans, lived with at least one chronic condition (Catlin, Cowan, Hartman, Heffler, & National Health Expenditure Accounts Team, 2008; Thorpe & Howard, 2006). Costs that were spread out for hospital care, physician and clinical services, and prescription drugs represented 62% of that total spending.
The impact of chronic illness is greater than economic terms alone; chronic diseases account for one third of potential life lost before the age of 65 years (Centers of Disease Control and Prevention, 2007). The impact of chronic disease and its consequences is much more acute impact among vulnerable populations, such as uninsured African Americans and Hispanics. Vulnerability to poor health is the result of interactions of many factors (Anderson & Knickman, 2001) encompassing individual, community, social, and political variables that impinge on individuals and groups in various ways. Among these factors, socio-economic variables are some of the most highly influential. The official poverty rate in 2007 was 12.5% with 37.3 million people in poverty, up from 36.5 million in 2006 (DeNavas-Walt, Proctor, & Smith, 2008). Viewed within this context, the potential impact of an innovative approach to health behavior change, such as the TPS, can be significant in chronic disease self-management among vulnerable individuals.
Implications for Health Care Reform
One obvious avenue for significant cost savings to the health care system is to prevent episodes where health care costs the most: hospitalizations and hospital readmissions. One obvious avenue for significant cost savings to the health care system is to prevent episodes where health care costs the most: hospitalizations and hospital readmissions. Since a major proportion of chronic diseases are managed in community-based primary care, it stands to reason that to have an impact on managing the overall costs of chronic disease care, prevention of expensive hospitalizations should be one of the major goals of disease management.
Current health care reform initiatives have focused on chronic disease and its management. These initiatives have identified models of care to promote effective management of chronic disease that will minimize episodes of high-cost care. Among them is the patient-centered medical home model, which focuses on principles that have always been the bedrock of primary care provided within a nursing model: holistic orientation; coordinated; integrated care; enhanced access; and quality and safety-based care (American Academy of Family Physicians [AAFP], American Academy of Pediatrics [AAP], American College of Physicians [ACP], & American Osteopathic Association [AOA], 2007).
Another complementary approach is the chronic care model that includes six critical elements: health care organization, community resources, self-management support, delivery system design, decision support, and clinical information systems (MacColl Institute, 2011). Within the chronic care model, specific approaches have been designed to facilitate self-management. One widely tested and well-disseminated approach, the Care Transitions Intervention, is based on four pillars: medication self-management; follow-up with primary care provider/specialist; knowledge of “red flags” or warning signs/symptoms and how to respond; and patient-centered records (Coleman, Parry, Chalmers, & Min, 2006).
This article describes one example of the patient navigator role to help patients manage their chronic disease(s). We present Transformation for Health, a paradigm that incorporated ideas and practices within several widely recognized models and approaches into a conceptual framework based on the concept of self-liberation and empowerment. This integrated approach was delivered through an interprofessional context, using as a base the practice of a paraprofessional group of community health workers. Transformacion Para Salud (TPS), a patient navigation model for chronic disease self-management, was a two year demonstration program to develop a culturally sensitive intervention to facilitate patient behavior changes. The article discusses the conceptual basis and implementation of the TPS and includes program evaluation, specific intervention outcomes, and implications for practice.
Role of Patient Navigator
Patient navigation was originally conceptualized at the National Cancer Institute (2012), where cancer care included patient navigators. The navigators were trained and culturally sensitive health care workers who provided support and guidance throughout the cancer care continuum. They helped people "navigate" through the maze of doctors' offices, clinics, hospitals, outpatient centers, insurance and payment systems, patient-support organizations, and other components of the health care system. Services were, and continue to be, designed to support timely delivery of quality standard cancer care and ensure that patients, survivors, and families are satisfied with their encounters with the cancer care system.
...the patient navigation model has been expanded to include the timely movement of an individual across the entire health care continuum... Dr. Harold Freeman, another pioneer in the patient navigation concept, contends that the patient navigation model has been expanded to include the timely movement of an individual across the entire health care continuum from prevention, detection, diagnosis, treatment, and supportive, to end-of-life care. Patient navigation has shown efficacy as a strategy to reduce cancer mortality and is currently being applied to reduce mortality in other chronic diseases. Thus, the concept of patient navigation can apply to a whole range of health care workers, from lay paraprofessionals to trained professionals such as social workers, registered nurses, and physicians (Harold P. Freeman, 2012).
Transformation for Health: A Conceptual Framework
Transformation for Health (TFH) is a framework that conceptualizes a transcendent process wherein people overcome oppressive conditions – whether these conditions are created through human design or from situational circumstances – that leads in different ways to the subjugation of the human spirit (Esperat et al., 2008; Esperat, Feng, Owen, & Green, 2005). Paulo Freire, a Brazilian educational philosopher, proposed that individual people or groups must achieve transformational power; it cannot be given to them. This is a powerful idea that can be used in health care practice to assist individuals, families, and communities to transcend conditions that promote health problems and concerns deleterious to wellbeing. Thus, it has particular significance in understanding and addressing health disparities among vulnerable populations.
Our organizing principle describes four phases, each with processes that lead to the goal behaviors. Both phase and process are essential components in the explanatory power of this framework. In the cognition phase, the individual will develop a critical consciousness that will lead to a deeper understanding of inherent realities. This is a very important first step in which the individual comprehends the nature of conditions and the ways that they affect life, and enables the realization that only the individual can control what can be controlled in the dynamics of transformation. The dawning of critical consciousness can be facilitated – this is where the helping person or professional can have an impact. This process of development requires that participants interact with each other in a horizontal rather than vertical relationship, engaged in real dialogue and communication which is humanizing and which makes every attempt at comprehending the other’s realities. In the health care relationship, this requires the health care provider (who frequently holds the balance of the power structure) to create a more balanced relationship and to take the health care receiver at the point of his emergence.
These actions lead to the intention phase, where the individual’s motivational system is activated by the critical consciousness awakened during the previous cognition phase, to assess capacities for the transformative process and to develop the will to change. In chronic disease, it is during this phase that the individual makes the decision to change the behaviors and elements of lifestyle that lead to difficulties in controlling the advance of the chronic disease and the multiple complications that lead to co-morbidities.
In the decision phase, the individual actualizes decisions that were made to change and maintain behaviors that promote effective and successful self-management of negative conditions. It implies acceptance of responsibility for the consequences and outcomes of decisions that have been made about the situation at hand.
During the transformation phase, self and guided evaluations will yield evidence of intermediate, and possibly, end results of the actions taken by the individual to improve management of the process. The pragmatic elements of Freire’s philosophy have practical application in chronic disease management because it requires direct involvement of the individual in the process of discernment and understanding of circumstances that have impact on disease progression.
We believe that this framework will have optimal application in the TPS program because the intensive work to bring people to independence in the management of chronic disease(s) requires a great deal of critical awareness awakening and relationship building that will facilitate transformational behaviors. Figure 1 diagrams the conceptual framework’s phases that the individual (or entity) goes through to achieve such transformational behaviors.
Community Health Workers as Patient Navigators
There is strong evidence of CHW’s success in managing social determinants of health, which is where their role as patient navigators is most valued. Community health workers have been used worldwide for over 300 years, but organized programs and documentation of their use began to gain attention in the 1960s in the United States. In 2007, the Health Resources and Services Administration (HRSA) released an extensive workforce study documenting the state of the science in the use of community health workers within the health care system. Results from several reports and research investigations were gathered and analyzed, which provided valid - if fragmented - evidence of CHW effectiveness in the delivery of health care, prevention, and health education for underserved communities (U.S. Department of Health and Human Service, Health Resources and Services Administration and Bureau of Health Professionals, 2007). A review of studies related to heart disease and stroke lent support for CHW interventions’ success in blood pressure care and control (Hill, et al., 1999; Hill, et al., 2003; Levine, et al., 2003), as well as in diabetes (Fedder, Chang, Curry, & Nichols, 2003). There is strong evidence of CHW’s success in managing social determinants of health, which is where their role as patient navigators is most valued (Hunter, et al., 2004; Lewin, et al., 2005) .
The TPS experience provides further evidence of the contributions of CHWs in the management of chronic disease, using the conceptual framework. However, much more research and evaluation of programs using CHWs in chronic disease management needs to be conducted to further build the evidence for this type of health care delivery. The following experience describes one example.
Table. List of Partners for the TPS Program
South Plains Food Bank
Food voucher; food stamp application assistance
Transportation provided through bus passes purchased
City of Lubbock Community Development Program /Backyard Mission/Adult Protective Services
Assistance with housing repairs
First Care /Superior
Medicaid and Medicare applications
Catholic Family Services
Prescription assistance, medical supplies, utility assistance
Covenant Community Outreach Adult Dental/CHCL
Dental extraction and dentures
Free glucometers with discount coupon for strips
Department of Aging and Rehabilitative Services
Prosthesis, wheelchair accessibility services
Copper Rawlings and Mae Simmons Community Center
The Transformacion Para Salud Intervention
This was a two-year demonstration program funded by the Bureau of Health Professions (BHPR) of the HRSA of the U.S. Department of Health and Human Services. The project was approved by the Texas Tech University Health Sciences Center Institutional Review Board (IRB). The intervention was implemented primarily by a cadre of four CHWs, called promotoras, certified by the Texas Department of Health, through the Texas Tech University Health Sciences Center School of Nursing CHW certification program. Aside from the 160 hour basic certification training program, the promotoras underwent six weeks of training in chronic disease management, as well as on the application of the Transformation for Health conceptual framework to facilitate behavior change among vulnerable populations.
Patients with diabetes, hypertension, asthma, co-morbidities of obesity, and depression at the Larry Combest Community Health and Wellness Center (LCCHWC), a federally-qualified nurse-managed health center, were referred by Family Nurse Practitioners (FNP) to the TPS program. These FNPs were part of the TPS team that held regular monthly meetings with the promotoras to discuss specific patient challenges in chronic disease management, and to collectively determine ways to manage those challenges. The senior FNP in the LCCHWC is directly involved in the supervision of the promotoras related to following algorithms used in chronic disease management and is the primary referral for the promotoras in clinical matters.
In addition, the promotoras held weekly team meetings with the Project Coordinator. Discussions focused on assisting patients to face day to day demands that reflected social determinants of health (e.g., basic needs for adequate food and shelter) that had to be met first before an individual could focus on the demands of chronic disease self-management.
...promotoras guided and taught their patients about effective use of community resources to address their sociocultural needs. A network of referral systems was formalized for the TPS program, to aid promotoras to facilitate patients’ abilities to face demands that social determinants of health imposed upon them. Relationships between established and new community partners were nurtured. Please see the Table for a list of partners and the services they provided. Through the community partner listed above, the promotoras guided and taught their patients about effective use of community resources to address their sociocultural needs.
Each promotora carried a case load of 50 enrolled patients who were managed with weekly home visits for the first month (4 visits), followed by bi-weekly visits during the second month, and then monthly visits, depending on the progress of patients in terms of their self-determined goals to manage their chronic disease(s). Home visits were augmented by telephone contacts as necessary.
Initial home visits focused on building trust and facilitating critical consciousness between the patient and the promotora. Initial home visits focused on building trust and facilitating critical consciousness between the patient and the promotora. Using motivational interviewing, the promotora guided the patient through understanding the realities of living with chronic disease within his or her individual circumstances. As the relationship strengthened, the promotora conducted measurements of the components of transformational behavior, such as health literacy assessments; assessments of the change process using the transtheoretical change model; social support; and other standardized assessment tools that measure constructs within the TFH framework. Using data from these tools, the promotora facilitated the patient’s efforts in developing weekly goals for self-care, and guided periodic evaluations of those self-determined goals.
As the patient progressed in obtaining skills and competencies needed to manage chronic disease, continued evaluations were conducted. These evaluations included assessments of the patient’s readiness to be phased out, based on established criteria for the purpose of weaning participants out of the program. As 200 participants were weaned and phased out of the program, a support group was established for those who wished to continue interactions with other participants and promotoras beyond their formal enrollment in the TPS program. At least 20 “graduates” of the program chose to participate in these support group meetings.
The Project Coordinator held regular and incidental management and direction of the promotoras, using reflective supervision. Together with designated administrators of the TPS program, she conducted an ongoing continuous quality improvement process, using such control tools as the Ishikawa diagram/cause-and-effect diagrams (Ishikawa, 1976), to perform root cause analyses for performance improvements in designated quality indicators.
Program Evaluation of TPS
Changes in clinical indicators targeted for each disease process included systolic and diastolic blood pressure for hypertension; Hemoglobin A1c; for diabetes; results of lipid panels such as cholesterol, triglycerides, low density (LDL) and high density (HDL) lipoproteins; and emergency visits/hospitalizations in asthma patients. Body mass index (BMI) and depression scores on the Personal Health Questionnaire (PHQ-9) were collected at intervals, along with multiple measures of behavioral indicators that were proxy measures for the constructs in the TFH framework, such as Diabetes Self-Efficacy, Chronic Disease Self-Efficacy, Personal Resource Questionnaire, among others (See Figure 2).
Figure 2: Transformacion Para Salud: Logic Model for Implementation Health (Esperat et al, 2008) Figure Reprinted with permission.
The clinic director, who was the senior nurse practitioner, was knowledgeable about her patients and therefore used the criteria established to refer patients to the navigation program. Organizational goals were established using pre-established algorithms constructed by the clinical team. The team effort between the provider, nurses, dietician, patient navigators, and the patient made it possible to communicate through the processes necessary to meet goals. The clinic director, who was the senior nurse practitioner, was knowledgeable about her patients and therefore used the criteria established to refer patients to the navigation program. Organizational performance indicators, such as percentage of patients successfully navigated, and those adhering with care management algorithms, were monitored and tracked.
Specific Intervention Outcomes
At the end of the two year demonstration project, a report submitted to the BHPR of HRSA showed significant improvements in the clinical biomarkers that were tracked at baseline, at six months, and at the end of twelve months of intervention, based on 152 patients who were consistently tracked for all clinical and behavioral parameters. The average HbA1c changed from 9.1 to 8.4, which was statistically significant. The average change in blood pressure was likewise statistically significant. Total Cholesterol, LDL, and HDL were slightly decreased, but Triglycerides was slightly increased. The changes on lipid panels were not statistically significant.
The paired t-test showed several major behavioral improvements through the navigation program. Compared with the baseline, the score for Self Efficacy of Chronic Disease Management and Diabetes Self Efficacy after navigation program were both significantly improved 1.07 (p<.001) and 1.13 (p<.001), respectively. All the subscales of Summary of Diabetes Self Activities form were significantly improved. Diabetes clients showed increased days per week for following a healthful diet plans (M=0.68, SD=2.05, p<.05), having five or more servings fruits and vegetables per day but less high fat foods (M=0.51, SD=1.78, p<0.05), doing more exercises (M=0.79, SD=2.34, p<0.05), following doctors’ recommendations on blood sugar testing (M= 1.01, SD=2.81, p<0.05), and checking the feet (M=1.37, SD=2.61, p<.001).
Partial analysis of cost effectiveness (CEA) of the program was conducted, based on the asthma disease management performance indicators of emergency room (ER) visits and hospitalizations. The basic CEA showed that the asthma management program was cost effective. The calculation of Return-on-Investment (ROI) was based on the Agency for Healthcare Research and Quality’s (AHRQ) formula and benchmarks. All assumptions made served to underestimate the effect of the program; that is, if an assumption had to be made, we chose the one that minimized the return or maximized the investment to provide the most conservative estimates.
We chose the target population of Texas residents to match the location of our program. Medicaid was assumed to be the most prevalent insurance type. Since the program targeted adults, only adult data were employed. Asthma patients of all stages were included. Only benchmark data from randomized controlled studies were used. Only treatments related to asthma was included in calculating cost. The cost perspective was Program. Productivity gain was not included in the calculation of Net Present Value (NPV) and return on investment (ROI). It was further assumed that about 50% of eligible patients would participate in a program like ours.
As indicated earlier, the current study was limited by the range of data of service utilization. Only emergency room (ER) visits and inpatient stay data were available. From our data, there was a 91.7% reduction in ER visits and a 50% reduction in inpatient stay. For other services, we conservatively assumed that there were no changes due to lack of data. It was further assumed that the planning horizon was 3 years and it would take 1 year until the program would achieve full impact. The annual program cost per participant from the current study was $6,360.8. The discount rate was set at 3%. With these values and assumptions, the resultant NPV was -$17,692, ROI=$0.02. We caution that these data are presented as preliminary results, since the time frame is too short, and maturity of the program is not assumed, given the brief time frame in the implementation of the program.
Implications for Practice
By focusing on the patient’s own realities, first and foremost, providers have to deal with issues that create barriers to the patient’s ability to meet the demands that health care can impose... Results of this two year demonstration project further support the value of investing in innovative models of care, especially those novel paradigms that are comprehensive and practical at the same time. One way in which health care delivery will be meaningful to recipients of care is by first providing a context of the care to be delivered, and then that this contextual approach should be individualized to the patient. The TFH framework can be used to provide that context. By focusing on the patient’s own realities, first and foremost, providers have to deal with issues that create barriers to the patient’s ability to meet the demands that health care can impose upon that patient. Use of the TFH framework integrates the social determinants that have to be dealt with before one can focus on those demands. To that end, the TPS program which delivers care using that framework has achieved significant outcomes in terms of facilitating and sustaining behavioral changes needed for chronic disease self-management.
Our experience suggests that the use of paraprofessionals who are adequately trained in delivering specialized health care complements and supplements traditional health care delivered by professionals. Thus as the concept of patient navigation becomes more widely known, one role for a professional nurse is the creation, management, and evaluation of interventions such as the one we have described. Several considerations for program development are important. First, this task shifting can be achieved with a high degree of success if the paraprofessionals are adequately trained, and mechanisms exist for ensuring that they are certified to carry out this specialized care.
...as the concept of patient navigation becomes more widely known, one role for a professional nurse is the creation, management, and evaluation of interventions...In addition, the program must ensure that an infrastructure exists to support the complex demands of implementation, including regular and ongoing evaluation of each program component. For instance, an evaluation plan should take into account assessments of program objectives at the individual level (e.g., improvements of clinical biomarkers, behavioral outcomes) and the organizational level (e.g., program outputs and processes, such as numbers of patients navigated and achievement of performance indicators at all levels).
Finally, cultural and linguistic congruence is a critical element to facilitate success of program implementation such as that using the TFH framework. Promotoras hired for this program were indigenous to the communities from which the patients originated, making them particularly sensitive to cultural and situational conditions that may have influenced patients’ abilities to respond to and manage the demands that self direction require. In order for patients to work through the process to full critical consciousness, the promotora had to support their efforts to understand both subjective and objective realities as they exist. This required that the promotora had the capacity to contextualize those realities within his or her own world view. It also required, in turn, a certain degree of congruence and correspondence with a patient’s view.
The TPS program we presented was based on TFH conceptual framework. The behavioral outcomes of this project are based on the constructs of the model, and were assessed using appropriate standardized measures of the constructs of interest. In testing the model through the TPS program, we were able to demonstrate that the application of the TFH framework worked in facilitating behavioral change among a group of vulnerable and medically underserved patients with chronic diseases in a primary care setting.
The concept of patient navigators is a growing and evolving role for both professional and paraprofessional level providers. The use of promotora navigators appears to be a cost effective method toward facilitating behavior changes in a population with chronic illness. The addition of these community health workers to the interdisciplinary health care team suggests one useful mechanism to improve access to quality, cost-effective primary health care services, particularly for chronic disease management.
This research was supported by Grant #H4MHP 11079 awarded by the Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services
M. Christina Esperat, RN, PhD, FAAN
M. Christina Esperat, PhD, RN, is currently the Associate Dean for Clinical Services & Community Engagement at Texas Tech University Health Sciences Center School of Nursing. In this role, Dr. Esperat has had significant experience in development of community-based health care, including administration of a nurse-managed federally qualified health center and creation of enabling services for vulnerable populations. She is the Project Director of the HRSA-funded Patient Navigator program.
Debra Flores, MHRM
Debra Flores, MHRM, is the project coordinator for the Patient Navigator demonstration project. She has a total of eleven years of experience in community health worker (CHW) program implementation for different chronic conditions including cancer, diabetes, hypertension, congestive heart failure and asthma. She wrote the 160 hour curriculum that was certified by the Texas Department of State Health Services which provided the basic training needs for the CHWs.
Linda McMurry, RN, DNP
Linda McMurry, DNP, RN, is the Executive Director of Larry Combest Community Health & Wellness Center, a nurse managed, public entity model federally qualified health center that serves a medically underserved population with significant health disparities. She has substantial experience in nursing administration and community-based organizations, and is currently responsible for the day to day operational and financial management of the organization.
Du Feng, PhD
Du Feng, PhD, is a Professor in the department of Human Development and Family Studies at Texas Tech University. She is a member of American Psychological Association, National Council on Family Relations, and Gerontological Society of America. Her expertise is in statistical analysis, research design, and applications of analytical techniques.
Huaxin Song, PhD
Huaxin Song, earned her PhD in nutrition and M.S. in Statistics from the University of Illinois at Urbana-Champaign. She is currently the lead analyst of school of nursing at Texas Tech University Health Sciences Center. She did the statistical analysis on the outcomes for the demonstration project.
Lynda Billings, PhD
Lynda Billings, PhD, MFA, is an Assistant Professor of school of nursing at Texas Tech University Health Sciences Center. She is experienced in Community Based Participatory Research that involves community outreach and the use of Certified Community Health Workers/Promotoras and a member of the TTUHSC School of Nursing Research Team.
Yondell Masten, PhD, RN, WHNP
Yondell Masten, RN, PhD, WHNP, is the Interim Dean, Associate Dean, and Professor of the school of nursing at Texas Tech University Health Sciences Center. Her experiences on management and evaluation of nurse practitioner programs provided valuable asistance on this project.
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© 2012 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2012
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