Integrating Community Health Workers to Improve Diabetes Prevention

This population based trial aims to understand the impact of peer health interventions on
panels of patients in a real clinic environment

Investigators will conduct a cluster-randomized trial to test the impact of peer health
coaches on prediabetic patients cared for by patient-centered medical home model (PCMH) teams
to:

1. Reduce the incidence of type 2 DM in pre-diabetic, PCMH patients;

2. Promote weight loss among pre-diabetic patients;

3. Increase patient activation levels, a measureable construct of engagement, efficacy,
skills, and confidence in managing one's health, among pre-DM patients, resulting in:

1. Improved secondary clinical outcomes: better glycemic and blood pressure control,
and lower Framingham risk scores;

2. Increased utilization of preventive services (e.g. MOVE!, TeleMOVE!, Healthy
Lifestyles, etc);

3. Improved health behaviors (e.g. making dietary and exercise changes); and

4. Develop, implement and assess strategies to recruit, train, and integrate peer CHW
health coaches within the PCMH model.

This study will test a scalable model of peer health coaching to address the millions of
patients at risk for Diabetes Mellitus (DM),using low cost, culturally congruent personnel to
promote prevention of DM in PCMH practice.

Inclusion Criteria:

- Having at least one HbA1c result in the prediabetic range (5.7-6.5%) in the 2 years
prior to the start date of Phase 2.

Exclusion Criteria:

- A diagnosis of DM, based on ICD-9 codes applied during ambulatory encounters in the 2
years prior to Phase 2

- Treatment with DM medication other than metformin (e.g. insulin or oral agents)

- age greater than 75 years

- exclusion by patient's PCP due to contraindication for lifestyle intervention or CHW
outreach.