A Chronic Care Management Framework Bridging Clinic, Home, and Community Care in a Mexican American Population

Abstract

Despite evidence that chronic care management improves outcomes, a framework designed for low income, uninsured populations is still needed to improve health disparities and guide further replication. We describe the Innovative Care for Chronic Conditions framework implemented by a coalition of clinics and agencies to address chronic care management for Mexican Americans with Type 2 diabetes mellitus who have low income and primarily uninsured. The core elements of the framework are described by clinic, home and community settings with community health workers playing an essential role in the delivery of community-based services that address the social determinants of health. Promising results are described. This framework expands the understanding of chronic care management approaches and contributes to further replication of the framework in diverse settings.

An expanded chronic care management approach to multiple chronic conditions in Hispanics using community health workers as community extenders in the Rio Grande Valley of Texas

“…The Salud y Vida program has been described elsewhere ( Reininger et al, 2022 ; Zolezzi et al, 2022 ). In brief, community outreach screenings and clinical laboratory reports at participating clinics were used to identify individuals with a diagnosis of T2DM and poor glycemic control (HbA1c ≥8%).…”

Participant engagement in a community health worker-delivered intervention and type 2 diabetes clinical outcomes: a quasiexperimental study in MexicanAmericans

“…The clinics refer these patients to the SyV programme. The intervention has been previously described 19…”

“…The intervention has been previously described. 19 Recruitment and enrolment were conducted by patient navigators employed by hospital or university partners and located at participating clinics to screen patients for eligibility in the programme. Navigators recruited adult individuals residing in Cameron and Hidalgo Counties.…”

Does integrated health management within a county medical consortium improve rural type 2 diabetic patients’ self-management behavior and quality of life? An empirical analysis from Eastern China

“…By connecting services from multiple healthcare providers, integrated health management helps boost service continuity while improving health behaviors and outcomes in patients with chronic conditions. These models have been successfully implemented in Australia, Russia, and other countries [16][17][18][19]. Studies show that patients with chronic conditions can benefit from it in terms of both health behaviors and outcomes [20][21][22].…”