Support for the Diabetes Team

At CHOP’s Diabetes Center, multiple staff members work as a team with each patient and family to help them manage their child’s diabetes.

CHW Tawana Casey (L) worked with this single-parent family, which was experiencing housing, food and utility insecurity. Tawana worked with PECO to have electricity reconnected so the child's insulin could be refrigerated. We have endocrinologists, nurse practitioners, certified diabetes educators, social workers, nutritionists, child life specialists and a psychologist who examine, teach and support each family. For most families, this comprehensive team approach puts their child on a path to successful diabetes management.

However, there are some families, often with lower socioeconomic status or from vulnerable, underserved populations, whose circumstances are so complex and stressful that they struggle to manage their child’s illness, resulting in poorly controlled diabetes, frequent Emergency Department visits, increased hospitalizations and higher complication rates.

CHOP has added a new member to the diabetes team for those families — a community health worker (CHW) — to provide the additional support they need to overcome the hurdles that have prevented them from safely and consistently managing their child’s diabetes.

Community health worker’s role

CHWs, as a nonmedical staff, help families manage the challenging parts of life that go beyond medical matters. They help families get on track to successfully manage their child’s diabetes and to position children to develop the life-long skills needed to manage their health now and in the future.

The CHW helps the parents and child identify the socioeconomic issues that make it difficult to focus on their diabetes care, create a plan to address these challenges and then work toward solutions.

While CHWs have a basic understanding of diabetes and its management, they are not a source of medical information and cannot answer specific diabetes-related or health questions. They can help families connect with someone from the Diabetes Center to answer those types of questions.

Each CHW works with an individual family for 12 months, visiting more frequently at the beginning and then, as progress is made, less frequently. Last year, our CHWs worked with 52 families and made a total of 350 home visits.

Building a community

One recurring theme CHWs report their families face is social isolation. To combat this feeling, CHOP has developed community support events to provide opportunities for families to connect with each other and the diabetes team, meet a variety of community-based vendors and resources, and join support groups lead by social workers and CHWs.

Children and teens also have the chance to get to know other kids with type 1 diabetes and, through facilitated discussion groups, share their experiences and learn coping techniques.

More than 130 families regularly attend these events, which have continued to grow in size since they started in early 2019.

Community health workers can help families:

• Arrange transportation to medical appointments, and help families navigate the healthcare system
• Create better communication between the family and the diabetes team to build a strong relationship
• Make connections with community support services for children and their parents (such as mental or behavioral health providers, if necessary)
• Identify where the family can get healthy food and learn how to prepare nutritious meals for the entire family
• Work with the child’s school to facilitate care during school hours and for extracurricular activities, and to improve communication between the school and family
• Ensure living conditions (housing, utilities, etc.) are not compromising diabetes management