1. A Health Center Team Care Approach to Chinese American Diabetes Disparities Winston Tseng, PhD, University of California, Berkeley Susan L. Ivey, MD, MHSA, University of California, Berkeley Ben Lui, MD, MPH, Asian Health Services Rosy Chang Weir, PhD, Association of Asian Pacific Community Health Organizations (AAPCHO) Elaine Kurtovich, MPH, University of California, Berkeley Liss Ieong, MBA, Asian Health Services Kelly Fang, RN, Asian Health Services Hui Song, MS, MPH, AAPCHO Melissa Ongpin, University of California, Berkeley APHA Annual Meeting Denver, Colorado November 6-10, 2010

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Winston Tseng, PhD No relationships to disclose.

3. Outline of Presentation (1)  Significance of project  Project aims  Overall research design  Diabetes team care intervention

4. Outline of Presentation (2)  Evaluation of team care intervention  Key informant interviews  Dissemination plans  Project team and community advisory committee members

5. Significance of Project  Diabetes prevalence among Chinese Americans has been estimated at 15%, about 2.5 times higher than the general US population. 1,2  Diabetes rates are 5-7 times higher for Chinese Americans than for Chinese in their native countries. 3  Chinese Americans may face barriers in accessing diabetes care, including lack of cultural orientation, lack of culturally proficient care, lack of health insurance, and inadequate health services for those with limited English proficiency, and they may have poorer outcomes. 1 Centers for Disease Control and Prevention, 2002 2 Cowie et al., 2003 3 Carter, Pugh, & Monterrosa, 1996

6. Project Aims (1)  Develop and engage the Chinese American community through community-academic partnerships in the Chinese community and a community advisory board  Assess community needs and resources available to the Chinese American community so as to develop a culturally and linguistically-tailored diabetes intervention

7. Project Aims (2)  Design, implement, and pilot an innovative patient- centered diabetes care intervention to address barriers for Chinese American diabetics at a community health center o Compare outcomes of the proposed new clinical approach with those of usual care; o Assess the feasibility of implementing the proposed new clinical approach on a larger scale o Examine the costs of implementing the clinical component of the initiative

8. Overall Research Design (1)  A collaboration between Asian Health Services (AHS), UC Berkeley’s School of Public Health, and the Association of Asian Pacific Community Health Organizations (AAPCHO).  Research activities were implemented at Asian Health Services, a community clinic in Oakland, CA, that primarily serves low income Asian Americans, many of whom are immigrants.  Focus groups with family members of diabetics, people at risk of developing diabetes, and community members  Development of a nutritional curriculum for medical assistants

9. Overall Research Design (2)  Evaluation of diabetes team care intervention o Patient surveys and medical records abstractions (HbA1c* and blood pressure) o Patient focus groups o Key informant interviews  Nutritional assessment key informant interviews with AHS medical assistants—evaluating baseline knowledge about nutrition for diabetics * HbA1c measures average blood glucose over a period of time

10. Team Care Intervention  Patients in one medical unit (intervention unit) received the intervention, while patients in another medical unit (control unit) did not receive the intervention.  The intervention included: o Meeting with the health coach (a medical assistant with special training) immediately before and after seeing the doctor o A follow-up phone call from the health coach 1 week after the physician visit o A counseling session with the dietitian about 2 weeks after the physician visit

11. Current Team Care Program Activities  Enhanced health coach training curriculum, including an improved nutrition curriculum that resulted from this project, was designed and training provided to the medical assistants in the intervention unit  Another medical unit within the clinic has now adopted a similar program.  At AHS’s new site, the Frank Kiang Medical Center, health navigators are receiving health coach training with the goal of eventually implementing a similar program.

12. Evaluation of Team Care Intervention  Enrolled 95 patients from the intervention and control units into the study. 92 subjects had follow-up HbA1c test results and were included in the analysis. A second analysis included only the 78 subjects who had HbA1c results between 5 and 8.5 months after the initial study physician visit.  Study subjects: o Have type 2 diabetes o Are of Chinese heritage o Are 18 and older o Had an HbA1c between 6 and 11  Interviewed and had clinical data abstracted from their medical records when they entered the study and approximately 3 and 6 months later

13. Evaluation of Team Care Intervention: Demographics of Study Participants (1) Control unit Intervention unit Overall n=39 n=78 Sexn (%) Male11 (28.2)16 (41.0)27 (34.6) Female28 (71.8)23 (60.0)51 (65.4) Age (mean)66.866.566.7

14. Evaluation of Team Care Intervention: Demographics of Study Participants (2) Control unit Intervention unit Overall n=39 n=78 Primary language spoken at home n (%) Cantonese 31 (79.5)24 (61.5)55 (70.5) Mandarin 3 (7.7)9 (23.1)12 (15.4) Other 4 (10.3) 8 (10.3) More than one language 1 (2.6)2 (5.1)3 (3.8) Years living in U.S. (mean) (n=76) 17.815.216.4

15. Evaluation of Team Care Intervention: Demographics of Study Participants (3) Control unit Intervention unit Overall n=39 n=78 Educationn (%) Less than high school graduate 30 (76.9)24 (61.5)54 (69.2) High school graduate/some college 7 (18.0)11 (28.2)18 (23.1) College grad/Graduate or professional school 2 (5.1%)4 (10.3)6 (7.7)

16. Evaluation of Team Care Intervention: Demographics of Study Participants (4) Control unit Intervention unit Overall n=39 n=78 Financial resources meet daily needs (n=74) n (%) Very adequately 0 (0) Somewhat adequately 26 (72.2)20 (52.6)46 (62.2) Not adequately 10 (27.8)18 (47.4)28 (37.8) Health insurance status Private insurance 0 (0)1 (2.6)1 (1.3) Public insurance 29 (74.4)26 (66.7)55 (70.5) Uninsured 10 (25.6)12 (30.8)22 (28.2)

17. Evaluation of Team Care Intervention: Demographics of Study Participants (5) Control unit Intervention unit Overall n=39 n=78 Health status (n=76) n (%) Poor 9 (23.7)11 (29.0)20 (26.3) Fair 21 (55.3)23 (60.5)44 (57.9) Good 5 (13.2)4 (10.5)9 (11.8) Very good 3 (7.9)0 (0)3 (3.9) Excellent 0 (0) Years since diabetes diagnosis (mean) 9.48.38.9

18. Evaluation of Team Care Intervention: Effects on HbA1c* (1) *HbA1c measures average blood glucose over a period of time **p value based on Student’s t-test Control unit Intervention unit p value** n=46 Mean HbA1c at Baseline 7.627.60 Mean HbA1c at 6 months 7.637.24 Mean of difference in HbA1c (6 months - Baseline) 0.02-0.36 0.1423

19. Evaluation of Team Care Intervention: Effects on HbA1c (2) Control unit n=46 Intervention unit n=46 p value* HbA1c not well- controlled (≥7%) (Baseline) 37 (80.4)33 (71.7) 0.4640 HbA1c not well- controlled (≥7%) (6 months) 35 (76.1)25 (54.4) 0.0480 *p value based on Fisher's exact test

20. Evaluation of Team Care Intervention: Effects on HbA1c* (3) *HbA1c measures average blood glucose over a period of time **p value based on Student’s t-test Control unit Intervention unit p value** n=39 Mean HbA1c at Baseline 7.627.59 Mean HbA1c at 6 months 7.657.19 Mean of difference in HbA1c (6 months - Baseline) 0.04-0.40 0.1045

21. Evaluation of Team Care Intervention: Effects on HbA1c (4) Control unit n=39 Intervention unit n=39 p value* HbA1c not well- controlled (≥7%) (Baseline) 32 (82.1)29 (74.4) 0.5843 HbA1c not well- controlled (≥7%) (6 months) 28 (71.8)21 (53.9) 0.1593 *p value based on Fisher's exact test

22. Evaluation of Team Care Intervention: Effects on HbA1c (5)  Power to detect a significant difference in change in HbA1c between groups was only 37% given the small sample size of this pilot study; therefore we cannot rule out the possibility of a Type II error.  Further analysis plans include a propensity score matched analysis (chosen due to small sample size) and a dose-response analysis.

23. Key informant interviews  Conducted with Asian Health Services staff before and after implementation of the Team Care Model intervention  1 physician (MD), 1 medical assistant (MA), 1 dietitian (RD) from the intervention unit and from the control unit

24. Key informant interviews— major themes related to the intervention  The intervention may be improving diabetes patient care.  Another diabetes program in Oakland Chinatown, Family Bridges, was available for diabetic patients during the study period.

25. Key informant interviews— other general themes  Patients lack understanding about and compliance with taking Western medications.  Providers that listen and are culturally sensitive to patients’ needs, beliefs, and life circumstances are key to patient compliance and diabetes management.  Coordination of care for diabetic patients is lacking.  Family support is important to a patient’s diabetes management.

26. Dissemination Plans  Presentations on findings o American Public Health Association o The project’s Community Advisory Committee o AHS Cantonese and Mandarin Patient Leadership Councils  Publication of findings o Chinese language newspaper and radio o AHS and AAPCHO websites o Scientific journal

27. Project Team  Susan L. Ivey, MD, MHSA, UC Berkeley  Winston Tseng, PhD, UC Berkeley  Ben Lui, MD, MPH, Asian Health Services  Rosy Chang Weir, PhD, AAPCHO  Elaine Kurtovich, MPH, PT, UC Berkeley  Meredith Minkler, DrPH, MPH, UC Berkeley  Melissa Ongpin, UC Berkeley  Liss Ieong, MBA, Asian Health Services  Kelly Fang, RN, Asian Health Services  Jing Liu, RD, Asian Health Services  Dong Suh, MPP, Asian Health Services  Hui Song, MS, MPH, AAPCHO  Katherine Chen, AAPCHO  May Wang, DrPH, UCLA  Wilfred Fujimoto, MD, University of Washington  Eva Yuen, RD

28. Community Advisory Committee  Angela Chen, Chinese Community Member  Tina Diep, Chinese Community Health Advocate, Asian Health Services  Gordon Fung, MD, MPH, Asian Heart & Vascular Center - UCSF Medical Center  Alfred Lin, Chinese Community Member  Angela Sun, MPH, Chinese Hospital - Chinese Community Health Resource Center  Siu Fong Tang, Chinese Community Member  Thuc Ly Vuong, Chinese Community Member  Jie Bin Wu, Chinese Community Member

29. For More Information and Acknowledgements  Winston Tseng, PhD, University of California, Berkeley, winston@berkeley.edu  Office of Behavioral and Social Sciences Research and the National Institute of Nursing Research, NIH grant number R21NR011187-01