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Peer-Support Care Models for Patients With Diabetes

Effective care models for chronic illnesses such as diabetes must include sustained self-management support for patients. Improved clinical outcomes in diabetes depend on patients' self-management behaviors, such as taking prescribed medications, following diet and exercise regimens, self-monitoring, and coping emotionally with the rigors of living with diabetes. Yet many patients face multiple barriers to effective diabetes self-management. These barriers include lack of sufficient knowledge of diabetes or its treatment; lack of self-confidence, motivation, or skills to manage diabetes well; lack of financial resources for medications and supplies; and other comorbidities and physical limitations. In addition, many adults with diabetes lack effective support from their families and friends for their diabetes self-management. Even with frequent face-to-face office visits, they need more sustained support.

Promising Self-Management Models

To address these barriers, care models must include cost-effective ways to extend self-management support beyond clinic visits with health care providers. More frequent telephone contact with a nurse care manager between medical visits is effective in improving clinical outcomes among patients with diabetes, but these programs are labor-and resource-intensive. Many health care systems lack the resources to implement intensive nurse-led case management programs. Peer support among patients with the same chronic health problem may be a particularly effective strategy to complement health professional-led outreach programs. Interventions that mobilize and build on peer support are an especially promising way to improve self-management support for patients with diabetes.

The most effective models combine peer support with a more structured program of education and assistance. To date, most peer support programs have focused on clinic-based group visits, peer-led training sessions, and support groups. Strong evidence supports the benefits of face-to-face group self-management programs that combine discussion of key self-management issues, peer exchange and support, and behaviorally-based approaches to strengthen diabetes care self-efficacy, problem-solving skills, and efforts to set and follow through on specific behavioral goals. Peers serve as excellent role models for participants. Moreover, peer leaders can more easily hold group sessions outside of normal working hours than can health care professionals. Peers can also maintain contact with program graduates, thereby providing them with continued self-management support.

Many peer-led programs follow a model that was first developed and evaluated by Lorig, et al. at Stanford University—the Chronic Disease Self-Management Program (CDSMP), or Tomando Control de Su Salud, the Spanish version. The CDSMP is a program for patients with chronic conditions including diabetes, and it involves weekly 2.5-hour sessions over a six week period. Program content includes individualized exercises and cognitive symptom management programs; methods for managing negative emotions such as anger, fear, depression, and frustration; and discussion of topics such as medications, diet, health care providers, and fatigue. Leaders teach the courses in an interactive manner designed to enhance participants' confidence in their abilities to execute specific self-care tasks (self-efficacy) and to promote discussion among participants and with peer leaders.

More recently, several peer-support care models tested in the VA resulted in significantly improved glycemic control when compared to usual nurse care management. These models supplemented periodic face-to-face sessions with peer mentor-led telephone support, or with telephone calls between paired patients facing similar diabetes self-management challenges.¹ Such programs can either have peer mentors or coaches, with a volunteer or paid diabetes patient providing assistance to other diabetic patients, or can be bi-directional peer-support models. Although one of the key mechanisms by which peer support may work is to activate patients by having them help others, few models using this approach have been evaluated.

Internet-based support groups and other uses of the Internet to mobilize peer support have grown significantly over the past decade. Internet-based interventions are promising because of their low cost and ease of dissemination, and they may provide alternatives to more labor-and resource-intensive clinic programs. Results of several recent randomized controlled trials suggest that adding peer-support components (also referred to as "e-community" components) to Internet-based interventions can increase their effectiveness.^{2, 3} An example of a successful program is the Internet discussion boards established for patients and their family members by the Joslin Diabetes Center.

Peer-support care models appear to provide a low-cost, flexible means to supplement formal health care support. When carefully designed and implemented, peer-support interventions can be a powerful way to help patients with chronic diseases live more successfully with their conditions.

References

1. Heisler, M. et al. "Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management: A Randomized Trial," Annals of Internal Medicine 2010; 153:507-15.
2. Tate, D.F. et al. "Effects of Internet Behavioral Counseling on Weight Loss in Adults at Risk for Type 2 Diabetes: A Randomized Trial," Journal American Medical Association 2003; 289:1833-6.
3. Lorig, K.R. et al. "Internet-based Chronic Disease Self-Management: A Randomized Trial," Medical Care 2006; 44:964-71.