Over 415 million people have type 2 diabetes (T2D) worldwide, but many of them do not receive the care that they need to manage such a complex, progressive disease. Conventional clinical care has struggled to reach and engage populations of persons with diabetes. When it does reach them, it often lacks the tools to help patients achieve—and sustain—the lifestyle changes needed to manage their diabetes and live full lives with the disease. Peer support and digital health tools can fill this gap and help transform diabetes care.

eHealth—through web-based resources and apps—offers a variety of supports for people with diabetes. These can provide a way of monitoring and tracking critical information like blood glucose readings, but also key behaviors like exercise and diet. Through a variety of platforms, these can be uploaded and monitored by clinical teams, including automated algorithms that flag values or patterns needing review and response by the team. Messages tailored to patterns in the individual’s clinical values and behaviors can provide highly personalized feedback and suggestions. One program, for example, contains over 2,000 messages in its library, providing a base for highly nuanced, motivating contacts with users. Additionally, eHealth apps can link individuals with each other, with clinical teams, and with other online resources, providing information about options for healthy food in a neighborhood or community.

 

Peer support

Peer support also offers rich resources for reaching people and encouraging their ongoing disease management. People respect doctors and nurses as providing expertise to guide them in what would be best for their diabetes. But they turn to others “like me” to figure out what will work for them and how they can incorporate a recommendation into their daily lives. Thus, the peer supporter, coming from the same neighborhood, sharing background or interests, or perhaps also having diabetes, has a utility that complements the expertise of the doctor, nurse, and dietitian. Research of those working with Peers for Progress has shown that peer supporters—nonprofessionals trained to provide assistance, encouragement, and linkage to clinical and community resources—can help patients improve their blood glucose and other parts of their diabetes management and improve their quality of life. In addition to this, those who report heightened anxiety, stress, or depressed mood show improved

Research of those working with Peers for Progress has shown that peer supporters—nonprofessionals trained to provide assistance, encouragement, and linkage to clinical and community resources—can help patients improve their blood glucose and other parts of their diabetes management and improve their quality of life. In addition to this, those who report heightened anxiety, stress, or depressed mood show improved emotional status and reductions in the rates of hospitalization that often accompany such psychosocial distress.

A systematic review of 47 published reports found that 44 of them (94%) found peer support significantly better than controls in reaching and benefitting those whom conventional prevention and care initiatives too often hardly reach—those with lower socioeconomic status, less education, or burdened by ethnic or other forms of discrimination.

 

Combining high-tech and soft touch

We may think of the “sizzle” of the high-tech eHealth app and the “just plain folks” character of peer support as having little in common. In reality, they overlap a good deal. The reliable, authoritative, always available app gives people a sense of it “having my back.” And the solid information and patient reminders of the peer supporter backed up by a clinical team can be a strong resource for living well with diabetes. So, what happens if we combine these, the “high-tech” and the “soft touch”?

A recent study conducted by Peers for Progress, in collaboration with WellDoc®, Vanguard Medical Group, and Horizon Blue Cross Blue Shield of New Jersey, developed and tested the feasibility and reach of integrating telephone-based peer support with an eHealth intervention (BlueStar® Diabetes) for diabetes self-management support in a progressive primary care practice in New Jersey. WellDoc’s BlueStar® Diabetes (BSD) is an FDA-cleared mobile prescription therapy that provides real-time patient coaching and support using algorithms driven by clinical and behavioral insights and delivers clinical decision support to the provider.

As we suspected, it turned out that peer support and BSD are actually very synergistic. Integrating these two forms of patient support has provided patients with more choices and more personalized care. Patients engaged with the program in various ways; some relied mainly on the peer support, some only needed BSD, but most used a blend of both. This provides then a nice way of offering individuals choices and enabling their “self-titration” to suit their needs and preferences.

The coaches successfully encouraged patients to continue using BSD, in the process developing good habits for monitoring their blood glucose, medications, and diet. Conversely, BSD was able to generate actionable data, prompt context-sensitive outreach, and guide decision-making for the coaches. Furthermore, BSD’s ability to handle the routine day-to-day tasks freed the coaches to spend more time addressing complex behavioral issues, such as developing coping strategies, overcoming barriers, and detailed problem-solving. In sum, technologies like BSD are valuable for facilitating the delivery of peer support, making support more sensitive and personalized, and providing automated functions that decrease the workload for peer supporters—all in addition to empowering people with more choices!

Interviews conducted with patients and the project team indicated that integrated peer support and digital health is feasible and well accepted. As further evidence of the program’s acceptability, we were able to sustain engagement with 70% of patients over a 6-month intervention period, in distinction to the often observed rapid drop-offs in use of digital or web-based resources over time. Patients received an average of 7 coaching contacts over 6 months. Of those receiving coaching, 86% used BSD, making an average of 6.5 entries in the app every week. Most respondents said that they would highly recommend this program to a family member or friend with diabetes.

Vanguard Medical Group is a NCQA-certified “patient-centered medical home” (PCMH), meeting a number of criteria for team care that focuses on patient engagement in self-management of the patient’s health, in collaboration with the provider and the care team. This proved to be an ideal setting for the integration of peer support and BSD. With care coordination processes and a team-based approach to whole person health, the Vanguard PCMH had the organizational mission and capacity to coordinate and sustain the program. Care coordinators provided coaching to the lay coaches and acted as liaisons between the coach and BSD reports and the providers who are ultimately responsible for the patient’s plan of care. In return, rich data from the lay coaches and BSD contributed to the quality of care delivered by the clinical team, including follow up and diabetes education.

Peer support and digital health exemplify a dramatic shift in healthcare delivery, from a top-down approach to a more collaborative and patient-driven approach. This project demonstrates that these innovative programs may be disseminated through “real world” patient-centered medical homes and have the potential to reach entire populations when implemented in concert with care coordination support.


Acknowledgements
This project was supported by a Gillings Innovation Laboratory ward at the UNC Gillings School of Global Public Health.
Edwin B. Fisher, PhD
Edwin B. Fisher, Ph.D., is Professor in the Department of Health Behavior in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. He received his Ph.D. in 1972 in Clinical Psychology from Stony Brook University. He is also Global Director of Peers for Progress, a program that is building the evidence base for peer support interventions, disseminating resources and guides for program development and quality improvement, and promoting networking among peer support programs to pursue integration of peer support in health care and preventive services around the world. In addition to his work in diabetes, his research has addressed health challenges in asthma, cancer, cardiovascular disease, smoking and smoking cessation, and weight management. His approaches to these problems have included self management, social support, and community based health promotion, including studies of community based programs for underserved, minority groups.

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