A patient with diabetes struggles to maintain the proper weight and follow a healthy diet. A mother with a young child who suffers from asthma forgets to purchase medication. In neither case would the patient necessarily need to visit a family physician's office to address the problem, but both situations are examples of pressing health needs that should be addressed before the condition gets worse.
Peer support workers at the Clinicas de Salud del Pueblo clinic in California review patient blood sugar records.
When a family physician or other health care professional is not able to reach out to these patients, a peer support health care worker can fill the gap in access to care. Peer support networks are composed of individuals who advise patients about the importance of healthy behaviors. Although they typically are not health professionals with medical training, they are trained to communicate with patients about their health needs.
A recent webcast pointed out the effectiveness of such networks. During the event, Edwin Fisher, Ph.D., global director of Peers for Progress(peersforprogress.org) at the AAFP Foundation, and Leticia Ibarra, M.P.H., director of programs for Clinicas de Salud del Pueblo, discussed the rising importance of peer networks.
Building a Bridge
"There's a tendency to treat peer support as frivolous things health centers do as a public relations strategy," said Fisher, a professor of health behavior at the University of North Carolina at Chapel Hill. "We feel that peer support can be a very powerful and important part of health care, of primary care and the patient-centered medical home."
- Peer support networks can fill in a communication or access gap that sometimes occurs between patients and their family physicians or other health care professionals.
- Peer support staff members can include volunteers, community health workers or coaches who are focused on detection, prevention and the behavioral aspects of chronic disease management rather than on treatment.
- Studies have found that patients are more likely to speak openly about health concerns with a peer.
Peer support is building a bridge between primary care and the specific health needs of the surrounding community in terms of the population base and local health needs. A key value of peer networks is to reach the "hardly reached," including residents in rural areas, individuals without insurance and patients who encounter barriers to health care access, said Fisher.
Peer support workers are not an extension of the physician. They do not diagnose, treat or prescribe, but they can accomplish multiple goals, including identifying high-risk individuals, meeting regularly with patients who have chronic conditions and providing regular advice on health care practices. Their presence can reduce readmissions to the hospital and improve community health without multiple visits to a primary care office. Most of the consultations can occur during a home visit or in a telephone conversation.
Peer support staff members include anyone from volunteers to community health workers to coaches. Many peer support workers have the same health problem as the patients with whom they consult. They are focused on detection, prevention and the behavioral aspects of chronic disease management rather than on treatment. According to information in the webcast, researchers have found that patients are more likely to respond to recommendations from peers or coaches who have the same affliction they themselves have.
In one study, home visits by nurses were found to reduce hospital readmissions among patients with heart failure by a substantial rate. Fisher noted that a trained peer support worker could do about 75 percent of what the nurses did in this particular study, so the same kind of follow-up is available for heart patients without always having to see a physician or a nurse.
Fisher believes peer support could be expanded to include rehabilitation for post-transplant patients, as well as patients recovering from cardiac or other major events. Given that many such patients also are elderly, they may not have the necessary support to take care of themselves. "If a peer came to visit them every other day and asked them whether they were taking their medicine, that would raise their morale and increase adherence," Fisher said in an interview with AAFP News.
Reaching Out to Patients
With peer networks, the value is the frequency of communication and the comfort level that develops between the patient and the health worker. Many patients visit a physician once and may not follow the prescribed treatment for more than a week after the visit. A patient's failure to do so could lead to another visit to the physician's office or a trip to the hospital. Despite such risks, patient outreach often is overlooked because of the daily demands on physicians and the office staff. "In many primary care settings, all people have time to do is get from 8 a.m. to 6 p.m.," Fisher said.
Initially, some physicians may be reluctant to partner with or build a peer support network into their practice out of fear they might lose control. "Family physicians are concerned about their relationship with patients," Fisher said. "They're very protective, and they don't want to create the perception that the care is being watered down."
However, peer support networks are ideal for small, rural communities that lack health facilities or for low-income populations without health insurance. A peer network can be based in a clinic or be a roster of health workers, coaches and volunteers spread out in a wider area. Fisher cautioned that just wanting to establish a peer network is not enough. The programs require dedicated staff.
"These networks need financing and support," said Fisher, noting that Peers for Progress has awarded grants to 14 peer networks internationally. "To think you can just recruit some volunteers and send them out to meet with patients and expect miracles without having to pay anyone isn't going to work."
Case Study in Integrating Care
One long-running peer support network is the Clinicas de Salud del Pueblo in Southern California, which opened in the 1970s. The facility's diabetes program recently obtained a grant from Peers for Progress that allows them to provide ongoing support for patients with diabetes. In keeping with the concept of integrated care, support visits and peer contacts are included in the patient's medical records.
Ibarra describes the peer networks as a bridge to primary care whereby health workers provide "ancillary" support to clinical care. A peer support worker who works 10-20 hours per week will be responsible for about six to 10 patients in the program.
Other initiatives at Clinicas include a team devoted to preventing teen pregnancy. Another group provides long-term care for patients with HIV infection who are counseled about finding housing and how to protect themselves in a relationship. The peer network model also has proven valuable in Spanish-speaking communities where coaches can communicate directly with patients in their own language.
Peer support workers often must serve as counselors, alleviating patients' fear about seeking medical care. The economics of health care frequently is one of the major barriers to access. As Ibarra explained, adults in low-income areas wait until they are very sick before seeking any kind of care.
"Cost is a primary concern," Ibarra said. "Many people don't have health insurance, and with the type of employment they have, it is difficult to get time off. The clinics do have long wait times, and some people are worried that we may not provide a solution they need."
According to Ibarra, however, when peer support groups are meeting with patients regularly, communication across the spectrum of care is improved. Clinicas operates on the principle that any health condition that requires fewer than four office visits per year should include some form of peer support.
A patient might tell a peer worker that he has grown weary of taking a particular medication, something the patient would be reluctant to tell a doctor or a nurse, said Ibarra. With that information in hand, the peer worker could ask the physician if some changes in medication are warranted.
"Peer support workers can explain the importance of health care," Ibarra said. "They can provide a cost analysis that tells a patient if they don't take time off, it could cost them more in the long run. The patient sees someone is there to listen to them, and they realize that the clinic does care."