CORAZÓN por LA VIDA May 24, 2011 A Community-Based Primary Care Intervention for Reducing Risks of Cardiovascular Disease among Latinos living in the New Mexico-Mexico Border Region

Hidalgo Medical Services & the Robert Wood Johnson Center for Health Policy at the University of New Mexico Funded by the Institute for Minority Health & Health Disparities, National Institutes of Health Presented by Lavinia Nicolae, RWJF and Carmen Maynes, HMS 4/4/2019

Hypertension: A Growing Public Health Problem in Rural New Mexico 21% of adults in Grant County have been diagnosed with hypertension. 57% of adults are obese or overweight (2003 BRFSS) Hidalgo County (1998 and 2002) hypertensive disease was the third leading cause of death. Hispanic low levels of hypertension awareness, treatment, and control (NM BRFSS, Behavior 2003) 4/4/2019

Goals To evaluate and compare the impact of community-based strategies (promotora intervention) with standard clinical care in relation to self-management of hypertension among Hispanics living in Hidalgo and Grant counties in New Mexico. RWJF partnered with HMS to assess whether Hispanic patients diagnosed with hypertension that receive standard clinical care plus promotora community-based interventions will show improvements in clinical, patient reported and economic outcomes compared to a control group receiving only standard clinical care. Using a mixed-method approach, this project will evaluate and compare the impact of community-based strategies (promotora intervention) with standard clinical care in relation to self-management of hypertension among Hispanics living in Hidalgo and Grant counties in New Mexico. Using a quasi-experimental two-group pre-post design, we will examine whether patients diagnosed with hypertension that receive standard clinical care plus promotore/community-based interventions will show improvements in clinical, patient reported and economic outcomes compared to a control group receiving only standard clinical care.

Promotoras Focus of the promotoras model is on “Treating the Whole person” through a community approach rather than just clinic-based health care Promotoras support patients to “take charge of their health” Promotoras are: patient advocates, health educators and trusted allies Promotoras involve community members and family networks Standard clinical care plus promotora/community-based- (intervention group)_ Each study participant will be linked to a HMS promotora who will provide one-to-one follow-up case management with each patient enrolled in the study and actively engage the participants in receiving primary care at HMS. Promotoras are part of the six HMS Family Support Centers located in or near each of the HMS health center sites in Hidalgo and Grant Counties. The promotora/community based intervention activities include: on-going nutrition and disease management education classes co-led by the health educator and promotore, family and social support, patient navigation of eligibility, benefits and financing options related to their HMS care and referrals to a menu of community interventions. Standard clinical care –(control) routine clinic appointments, laboratory tests, medications, and referrals as necessary. In addition, a standardized packet of diabetes education materials, presented in both Spanish and English and tailored for the local Hispanic population, will be provided during the initial visit during the study period regardless of group assignment. This intervention will be provided by an existing cadre of 21 primary care providers at HMS (physicians, nurses and physician assistants).

Participants Sample of 128 Hispanic patients (64 female and 64 male) from among the pool of Hispanic hypertension patients actively enrolled in HMS (Group A). adults 18+ years and older with an existing hypertension diagnosis and one or more risks factors associated with hypertension (smoking, high cholesterol, high blood pressure) but have no pre-existing diagnosis of diabetes (free of diabetes) or substance abuse disorders under the ICD-9 diagnosis codes used by Hidalgo Medical Services. Group B (Control) will comprise the remainder of Hispanic patients who are not in Group A. Sample of 128 Hispanic patients (64 female and 64 male) from among the pool of 580 Hispanic hypertension patients actively enrolled in HMS (Group A). Group B (Control) will comprise the remainder of Hispanic patients who are not in Group A. Targeted sample size is 128 adults 18+ years and older with an existing hypertension diagnosis and one or more risks factors associated with hypertension (smoking, high cholesterol, high blood pressure) but have no pre-existing diagnosis of diabetes (free of diabetes) or substance abuse disorders under the ICD-9 diagnosis codes used by Hidalgo Medical Services. Socio-demographic characteristics will be collected using a clinic visit survey from both Group A and B (e.g. gender, age, education, employment, sub-ethnic group (i.e. Mexican), language proficiency/preference.

Challenges The program has completed two waves of the education and treatment. Pre and Post intervention focus groups and surveys Timeline of the project – modifications were created to meet deadlines Time line of project: Went from 2 years to 1 year. Study Recruitment for the first two waves. Little luck in Silver City More responses in Bayard and Lordsburg - Promotoras had 3 weeks before intervention was started to recruit participants. This coupled with training was a challenge for 3 Promotoras to complete. The timeline for recruitment, program implementation, and evaluation have all been pressed into a one year period, which poses its own set of issues including program modification throughout the intervention. Promotoras had to learn to adapt to evaluation process. 4/4/2019

Challenges and Lessons Learned Pulling data from surveys, classes and e-Clinical Works (EMR) from HMS. Initial HMS patient pool contained diabetics and Caucasian patients Unrecorded information like blood pressure measurements missing from Promotora home visit and from e-Clinical Works, demographic information. (My Habits survey) Difficulty completing surveys. Participants are asked to complete the survey prior to intervention, after intervention, at 3 and 6 months. Focus group recruitment Little luck in Silver City Not enough people for pre-intervention for first two waves Familiarity with the program may have been an issue. Trust. Not understanding what a focus group is Promotoras experience with recruitment. 4/4/2019

Challenges and Lessons Learned Conducted post-intervention focus group for second wave Best turnout for female group. Not so good for male and family. Only 1/3 of participants in family showed up (4 out of 11) and 2 out of 8 for males. Points of interest in Focus Groups. Perceptions about eating differently and giving up traditional foods or cooking them differently. Some silent resistance. Access to food resources Financial concerns Travel difficulties: people’s willingness and ability to travel. 4/4/2019

Challenges and Lessons Learned Difficulties completing gendered study. How to get to gender while working with limitations. Participation in program Participation in focus groups 4/4/2019

Opportunities Opportunity to address community concerns with community participation. Opportunity to create programs that community members and clientele can relate to. Opportunity to integrate clinical and Promotora interventions to improve patient health Improve UNM relation with communities. Gaining positive presence and build trust with local organizations. 4/4/2019

Next Steps Develop a non-specific Promotora intervention program. Grant writing to develop such a program for across the board chronic diseases. Future collaboration on additional projects or expanding current project. 5/22/2011