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Monday Sep 17, 2018

I Hired a Community Health Worker and Now We Work Miracles

Physicians see some patients over and over again without making progress in improving their health.

Here I am, left, with community health worker Loetta Adkins, who has helped my practice improve results for patients who needed extra help.

Maybe they have diabetes and their A1c climbs despite our efforts to add medications or increase doses of insulin.

Maybe they struggle with obesity and we counsel them to improve their diet or incorporate more exercise, yet they have gained more weight at each visit.

Maybe we struggle to diagnose their complaint. Sometimes we struggle to understand why they have come to see us.

These patients have the most potential to improve morbidity and mortality rates, but they also are the group that is the hardest to connect with as we try to make those goals a reality. That's why success with these patients is one of the things that makes our jobs rewarding. These are the patients who absolutely make our day when we see a positive change in their lives.

Diabetes is the easiest illustration of this pattern because it requires intense commitment on the patient's behalf, and too often people don't have the means to control their sugar regardless of how many tools we hand them.

We know one of the foundations of family medicine that makes our relationships with patients so valuable is the trust they have in us. We work hard to create an environment in our exam rooms that feels open and welcoming, where patients feel comfortable revealing their concerns, fears and complaints. Despite our best efforts, however, sometimes we fail to solve their cases. Maybe we don't ask the right question, maybe the patient lies to avoid having the tough conversations necessary to truly be helped, but in the end all that matters is that we make no progress in lowering their blood glucose.

These relationships -- the ones where I feel I'm beating my head against an exponentially increasing hemoglobin A1c that refuses to budge despite what feels like buckets of insulin and metformin -- are exhausting.

About a year ago, I was fortunate enough to hire a community health worker with grant funding from the Appalachian Regional Commission through Marshall University. I am not exaggerating when I say I have a miracle worker on staff now.

Her name is Loetta Adkins.

When I get that feeling the patient and I are looking each other in the eye but something is "off," I get Loetta involved.

Every time I'm asked to describe the role of a community health worker, I give a different answer. You can't define something that is constantly changing. Each patient has a different need, and that need is often up to the community health worker to figure out.

The most valuable lesson I've learned is that I could never have imagined what is keeping most of my patients from controlling their diabetes. No amount of medical school or residency education could have prepared me because these interventions aren't medical, they are MacGyver-level humanitarianism.

Loetta sees patients in their homes, in our office, at Tudors Biscuit World -- basically wherever it's convenient for the patient. Last week, she saw one patient in her driveway and helped another she only communicates with via email. Others have no telephone, so Loetta literally has to show up unscheduled and unannounced.

Fortunately, I practice in a small town, and Loetta is from the area, so I haven't had much pushback from patients when I ask if I can send someone to their house to help me help them. Only two of the approximately 30 patients I've asked have declined.

I was established in my area before Loetta came along. I had been here for three years, so some of these patients I had been seeing for more than a year -- a few for all three -- with no progress.

Conversely, I could write a novel about her successes.

Three cases stand out as awe-inspiring examples that I could never have accomplished without her.

One is a patient who established with me in my first month out of residency. She was new to the area, having moved here to care for a family member. She had all the diagnoses: diabetes, chronic pain, COPD, heart disease, obstructive sleep apnea and sequela of uncontrolled diabetes: chronic kidney disease and neuropathy. We had increased to the concentrated insulins, had attempted referrals for some of her comorbidities, but nothing was improving. Actually, she was getting worse.

Within the first visit, Loetta was able to tackle the unexpected thing that was holding the patient back. She couldn't afford to cremate her cat who had died and wouldn't spend money on her own health care needs until that task was completed. Loetta negotiated a lower rate with the crematorium, took up a collection at the office, and when she returned the ashes to the patient she also made some repairs in the kitchen so the patient could safely cook again. Within three months, we saw her lowest A1c since she moved to West Virginia, and we got some long-awaited imaging tests completed.

Loetta helped saved another patient's life after witnessing anginal events as he carried water from a tank to the camper in which he was living. I couldn't convince him to see a cardiologist, but two weeks later Loetta talked him into it, and within a month he was admitted for open heart surgery. She also kept the patient's wife from potentially going into diabetic ketoacidosis after he was admitted to the hospital by recognizing that the wife didn't know how to administer insulin. (Her husband typically did it for her.) The woman is now completely off insulin, and her diabetes is diet-controlled.

My third success story is a patient who has overwhelming communication challenges due to a stroke. His blood sugars were running so high that his meter would only read "high" all the time. He can't write due to the stroke deficits, most of his speech is unintelligible (with the exception of expletives), and he has no telephone or support. The risk of starting insulin without a good means of monitoring sugars closely was daunting. We started by having him show up at the office the same time and day of the week every week. It took weeks to get him to show up with his glucose meter and his insulin pens. It took two months to finally start seeing glucometer readings under 300. We are finally making progress, but it has taken hours of Loetta trying to understand what he is doing so I could then make changes to his medications. She has also helped him schedule appointments with subspecialists.

That's not all. Loetta will exercise with patients. She has noted unhealthy food in patients' homes and offered them healthier alternatives. I have seen her find a wardrobe for a patient, wash sheets for another, and find transportation to get them wherever I've been begging them to go. And despite her small stature and grandmother status, she is fearless, going without hesitation into settings others would shy away from.

She is working to start a food bank and is training to teach geriatric chair yoga. Her successes have prompted one of the West Virginia Medicaid plans to ask us to expand our efforts, and we are moving into an exciting realm of actual insurance-sponsored community health worker activity.

Patients need doctors, but we aren't all they need to achieve better health. Sometimes they need things that seem impossible, and somehow community health workers make miracles happen.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.(twitter.com)

Posted at 02:49PM Sep 17, 2018 by Kimberly Becher, M.D.

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