Community-based outreach associated with increased health utilization among Navajo individuals living with diabetes: a matched cohort study

BMC Health Serv Res. 2020 May 25;20(1):460. doi: 10.1186/s12913-020-05231-4.


Background: Navajo community members face high rates of diabetes mellitus and other chronic diseases. The Navajo Community Health Representative Outreach Program collaborated with healthcare providers and academic partners to implement structured and coordinated outreach to patients living with diabetes. The intervention, called Community Outreach and Patient Empowerment or COPE, provides home-based health coaching and community-clinic linkages to promote self-management and engagement in healthcare services among patients living with diabetes. The purpose of this study was to evaluate how outreach by Navajo Community Health Representatives ("COPE Program") affected utilization of health care services among patients living with diabetes.

Methods: De-identified data from 2010 to 2014 were abstracted from electronic health records at participating health facilities. In this observational cohort study, 173 cases were matched to 2880 controls. Healthcare utilization was measured as the number of times per quarter services were accessed by the patient. Changes in utilization over 4 years were modeled using a difference-in-differences approach, comparing the trajectory of COPE patients' utilization before versus after enrollment with that of the control group. The model was estimated using generalized linear mixed models for count outcomes, controlling for clustering at the patient level and the service unit level.

Results: COPE enrollees showed a 2.5% per patient per quarter (pppq) greater increase in total utilization (p = 0.001) of healthcare services than non-COPE enrollees; a 3.2% greater increase in primary care visits (p = 0.024); a 6.3% greater increase in utilization of counseling and behavioral health services (p = 0.013); and a 9.0% greater increase in pharmacy visits (p < 0.001). We found no statistically significant differences in utilization trends of inpatient, emergency room, specialty outpatient, dental, laboratory, radiology, or community encounter services among COPE participants versus control.

Conclusions: A structured intervention consisting of Community Health Representative outreach and coordination with clinic-based providers was associated with a modest increase in health care utilization, including primary care and counseling services, among Navajo patients living with diabetes. Community health workers may provide an important linkage to enable patients to access and engage in clinic-based health care.

Trial registration: NCT03326206, registered 10/31/2017, retrospectively registered.

Keywords: American Indian; Clinic-community linkages; Community health representatives; Community health workers; Diabetes mellitus; Health disparities; Health utilization; Navajo.

Publication types

  • Observational Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • American Indian or Alaska Native / psychology*
  • American Indian or Alaska Native / statistics & numerical data
  • Case-Control Studies
  • Community-Institutional Relations*
  • Diabetes Mellitus / ethnology*
  • Diabetes Mellitus / therapy
  • Female
  • Humans
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / ethnology*
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Program Evaluation
  • Prospective Studies

Associated data