A clinic-based pilot intervention to enhance diabetes management for elderly Hispanic patients

Background and Objectives: Successful diabetes self-management requires behavioral and lifestyle changes. However, low-income patients may face challenges related to poverty that make it difficult to engage in lifestyle changes. We piloted an intervention designed to help older, low-income, Hispanic, patients with diabetes access free or low-cost community resources to enhance diabetes self-management. Results from this pilot intervention are reported.

Design and Methods: Patients were recruited at baseline to complete surveys assessing diabetes self-care activities, diabetes self-efficacy, and general self-efficacy. Volunteers were trained by a clinic social worker to help patients identify needs and make referrals to local community resources (e.g., housing, transportation, food, clothing, dental and prescription services, employment, or family social services). Identical surveys were administered at 3-month follow-up.

Results: 28 patients were recruited at baseline and 18 patients completed the follow-up assessment. No significant changes in diabetes care and self-efficacy were detected. All patients requested at least one referral to a community resource. The most common requests were for low-cost dental clinics, food assistance, and housing support. At follow-up, nine (50%) patients contacted their given referrals.

Conclusions: The need for assistance with basic social services is high in this population. The rate of referral uptake (50%) is high for a relatively low intensity intervention. Since the completion of the pilot, the program has trained 21 volunteers and helped over 220 patients in a primary care clinic. Using a volunteer model and creating connections to existing community resources is a cost-conscious way to deliver needed services to patients.

This article is included in the PCORI Social Needs Interventions to Improve Health Outcomes Evidence Map. Click here to access evidence map.