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Service Delivery Innovation Profile

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients


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Snapshot

Summary

The University of Pennsylvania Health System embeds community health workers into its clinical teams at hospitals and medical offices. Following the Individualized Management for Patient-Centered Targets (more commonly referred to as IMPaCT) model, the community health workers provide low-income patients with emotional support and help them navigate the health system and obtain appropriate care and community-based services and support. In the inpatient setting, they provide support both in the hospital and for at least 14 days after discharge, while in the outpatient setting they support chronically ill patients for 6 months. In both settings, they work with patients to develop goals and related action plans and provide customized support, including connections to needed services. In a randomized trial at two academic medical centers, the inpatient component of the IMPaCT model improved discharge-related communication, enhanced access to postdischarge primary care, and increased levels of patient activation, leading to fewer readmissions and depression-related symptoms and to positive feedback from patients.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized, controlled trial that compared key metrics among those participating in the inpatient component of the program with a similar group of patients who did not. Metrics include patient assessments of the quality of discharge-related communications, likelihood of accessing postdischarge primary care, 30-day readmission rates, depression symptoms, and levels of patient activation.
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Developing Organizations

University of Pennsylvania Health System
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Date First Implemented

2011
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Patient Population

Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Low-income individuals face above-average risk for poor health outcomes from chronic illnesses and for readmission and death after a hospital stay. Yet their clinicians often do not have the time or community contacts to support these individuals and connect them to the care and services they need. Community health workers (CHWs) can often play this role effectively, but relatively few care delivery settings employ them or otherwise use their services.
  • Increased risk of poor health outcomes: Low-income individuals tend to have poorer health outcomes and higher mortality rates than the general population. This disparity exists both in the outpatient setting (e.g., patients managing chronic conditions such as diabetes and hypertension)1,2 and during the postdischarge period after a hospitalization. Compared with the general population, low-income patients are less likely to access primary care and face a higher risk of readmission and death after being discharged from the hospital. For example, a study at an urban tertiary care center found that uninsured patients were less likely than those with insurance to receive timely primary care after discharge (29 versus 56 percent).3 An analysis of inpatients with heart failure found that those living in low-income areas and those covered by Medicaid had a significantly greater likelihood of readmission and death.4
  • Limited ability of clinicians to help: Clinicians in medical offices and hospitals often do not have the time, skills, or community contacts to help low-income patients address their health and related needs.5 Furthermore, low-income patients sometimes mistrust medical personnel and prefer receiving support from individuals in their own communities.5
  • Unrealized potential of CHWs: CHWs generally have similar backgrounds as the patients they serve and often live in the same communities. Trusted, knowledgeable members of the community, CHWs have been shown to enhance access to culturally competent, cost-effective care, particularly for those with chronic diseases.6 However, widespread use of CHWs has been hampered because programs are often poorly standardized, disease-specific, or lacking in rigorous scientific evidence.

What They Did

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Description of the Innovative Activity

The University of Pennsylvania Health System embeds CHWs into its clinical teams at hospitals and medical offices. Following the IMPaCT model, these CHWs provide low-income patients with emotional support and help them navigate the health system and obtain appropriate care and community-based services and support. In the inpatient setting, CHWs provide support both in the hospital and for at least 14 days after discharge, while in the outpatient setting they support chronically ill patients for up to 6 months. In both settings, CHWs work with patients to develop goals and related action plans and provide customized support, including connections to needed services. Key program elements are detailed below:
  • Target population of low-income, uninsured individuals/Medicaid beneficiaries: The inpatient program serves hospitalized patients who are uninsured or on Medicaid and live in one of five ZIP Codes where more than 30 percent of residents live below the Federal poverty level. The outpatient program serves the same target population, with the additional requirement that the individual have at least two of following chronic conditions: diabetes, hypertension, obesity, and tobacco use. The program currently serves approximately 1,000 patients a year.
  • Inpatient support through postdischarge transition to primary care: CHWs working on inpatient clinical teams receive referrals from a program coordinator who identifies eligible patients. CHWs work with the patients during and after the inpatient stay, generally until the patent has his or her followup primary care appointment. As outlined below, the inpatient-based CHWs work with patients to set recovery-related goals and an action plan for achieving them, provide support to the patient and interact with the care team throughout the inpatient stay, and ensure a connection to a primary care provider for followup care.
    • Goal setting and action plan on day of admission: A CHW visits each eligible patient on the day of admission. Using a semistructured interview guide, the CHW works with the patient to set one or more measurable goals for his or her recovery. The CHW asks the patient to list what services and support will be needed to stay healthy after discharge and helps identify and address any barriers to meeting those requirements, such as psychosocial issues and financial concerns due to lack of insurance and/or high medication costs. During this session, the CHW and patient jointly create an individualized action plan that lists the goals, the patient's level of confidence in achieving them, the resources required, and a step-by-step plan for achieving each listed goal.
    • Support to care team and patient throughout and after hospitalization: Throughout the inpatient stay, the CHW explains the patient's goals to the other members of the care team. The CHW also reviews discharge instructions with the patient, obtaining clarifications from providers as necessary. After discharge, the CHW continues to support the patient in achieving his or her goals through periodic phone calls, texts, and/or visits. During these communications, the CHW often provides emotional support and encouragement and suggests and provides connections to community-based services that can help, such as medication assistance, shelter, childcare, and food programs. Rather than just giving referrals, CHWs often accompany patients to show them how to access services, such as food pantries, substance abuse counseling, or even local recreation centers.
    • Connection to primary care: Before discharge, the CHW encourages the patient to make and attend a followup primary care appointment. In some cases, the inpatient CHW may attend the appointment with the patient. If the patient expresses dissatisfaction with the primary care provider, the CHW will help find a new one. The CHW stays in touch with the patient for at least 14 days after discharge, generally providing goal-related support until the followup appointment has been completed.
  • Outpatient support: CHWs work in medical practices that serve low-income patients with multiple chronic conditions. Coordinators in the practice review upcoming appointments, identify eligible patients, and notify the CHW that a patient is eligible. As detailed below, CHWs work with patients for a period of 6 months, developing goals and action plans, providing ongoing emotional support, and connecting them to needed community services, including to a peer support group.
    • Goal setting and action plan at initial meeting: The CHW meets eligible patients at the time of their appointment to explain more about the program. CHWs work with interested patients and their physicians to establish a concrete goal related to one of the patient's chronic conditions to be achieved within 6 months. The CHW and patient also discuss short-term interim goals that can serve as milestones along the way, along with any barriers to achieving these milestones and strategies for overcoming them. As with the inpatient program, the CHW and patient create an individualized action plan for meeting the 6-month goal and the interim milestones.
    • Ongoing support for 6 months: The CHW works with the patient over 6 months to achieve his or her stated goal. During this time, the CHW provides emotional support and recommends community resources and/or new strategies that can help.The CHW contacts the patient at least once per week through home visits, phone calls, or texts. The CHW provides coaching, helps to coordinate chronic disease care, encourages self-monitoring behavior (e.g. checking glucose), and accompanies patients to services based on patients’ action plans. For example, CHW might exercise with patients at the local YMCA.
    • Connection to peer support group: At the end of the 6-month period, the CHW encourages the patient to join a CHW-led weekly support group. The group generally includes other, similar patients with similar goals. Patients can participate in the support group indefinitely on a drop-in basis.

Context of the Innovation

The University of Pennsylvania Health System, an academic health system that includes the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Pennsylvania Hospital, has nearly 15,000 employees and handles roughly 80,000 admissions each year. The health system’s service area encompasses inner-city Philadelphia, which includes low-income communities with residents at risk for poor health outcomes.

The impetus for this program came from clinicians treating low-income patients who faced multiple challenges that negatively affected their ability to prevent, manage, and/or recover from both acute and chronic illnesses. These clinicians wanted to find a way to help patients address these challenges and hence began exploring the idea of using CHWs.

Did It Work?

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Results

The inpatient component of the IMPaCT model improved discharge-related communication, enhanced access to postdischarge primary care, and increased levels of patient activation, leading to fewer readmissions and depression-related symptoms and to positive feedback from patients,5 as shown in Figure 1. (Note: An ongoing randomized, controlled trial is evaluating the IMPaCT program in the primary care setting.)
    A chart showing the improvement in ten areas of care for IMPaCT participants

    Figure 1: Two-week IMPaCT results on 10 reported outcomes for 446 patients. Click the image to enlarge. Courtesy of Penn IMPaCT Community Health Workers. Used with permission.

  • Better communication related to discharge: In a randomized, controlled trial at two academic medical centers (Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania), participants were more likely than nonparticipants to report high-quality communications related to discharge, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (more commonly known as HCAHPS) discharge communication score (91.3 versus 78.7 percent).
  • Enhanced access to postdischarge primary care: Participants were more likely to obtain postdischarge primary care than nonparticipants (60.0 versus 47.9 percent).
  • Higher patient activation: Compared with nonparticipants, participants were more confident in their ability to manage their own care, as indicated by higher average scores (an increase of 3.4 versus 1.6 points) on the Patient Activation Measure. (A 3-point difference is considered to be clinically meaningful.)
  • Fewer readmissions: Participants were less likely than nonparticipants to be readmitted to the hospital within 30 days of the previous discharge (2.3 versus 5.5 percent).
  • Fewer depression symptoms: Participants increased their score on the 12-item Short Form (a self-reported test measuring symptoms of depression) by an average of 6.7 points on a 100-point scale, compared with a 4.5-point average increase for nonparticipants.
  • No differences on other measures: Participants and nonparticipants exhibited no statistically significant differences on measures of self-reported physical health, patient satisfaction with medical care, or medication adherence.
  • Positive feedback from patients: Participants reported high levels of satisfaction with the program, finding CHWs to be accessible, supportive, and effective in dealing with their practical and emotional needs.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized, controlled trial that compared key metrics among those participating in the inpatient component of the program with a similar group of patients who did not. Metrics include patient assessments of the quality of discharge-related communications, likelihood of accessing postdischarge primary care, 30-day readmission rates, depression symptoms, and levels of patient activation.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Enlisting key stakeholders: A University of Pennsylvania Health System physician (Dr. Shreya Kangovi) enlisted the assistance of various stakeholders, including the chair of medicine, two senior researchers, and a representative from the patient community. The team submitted an application to the health system's institutional review board for approval to conduct qualitative interviews in the community.
  • Conducting patient interviews: Between July 2010 and April 2011, researchers conducted indepth qualitative interviews with 115 chronically ill and hospitalized patients living in low-income neighborhoods to identify factors contributing to their poor health outcomes and solicit ideas for improving their care.
  • Designing model: Based on the information gathered during the interviews, the team designed the IMPaCT model, including components covering the identification of target patient populations; budgeting; and CHW recruitment, evaluation, supervision, and training.
  • Training CHWs: CHWs attended a month-long training program that covered various topics, including identifying barriers to care faced by low-income patients, motivational interviewing, maintaining professional boundaries, and trauma-informed care. The training was designed to address the needs voiced by high-risk patients in the qualitative interviews.
  • Conducting trial: Between April 2011 and October 2012, researchers conducted the aforementioned randomized, controlled trial involving 446 patients that evaluated the impact of the program in the inpatient setting.
  • Creating dedicated center to house and expand program: Based on the promising results from the clinical trial and positive feedback from providers, the health system created the Penn Center for Community Health Workers in 2013. Housed within Penn Home Care and Hospice Services, this center now serves as the home for the IMPaCT program. By the end of 2014, the center will employ 30 full-time staff (a director, assistant director, 24 CHWs, and 4 social workers to manage teams of CHWs), with the goal of serving 3,000 patients a year.

Resources Used and Skills Needed

  • Staffing: Inpatient CHWs generally handle a caseload of 6 patients (roughly 150 patients a year), and outpatient CHWs typically handle 25 patients at a time (roughly 50 to 60 a year). CHWs must have at least a high school diploma and demonstrate qualities such as empathy and reliability and possess active-listening skills.
  • Costs: The cost of program operations is approximately $500 per patient, including staff salaries, training, transportation for the CHWs, and other administrative costs.
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Funding Sources

University of Pennsylvania Health System
The Penn Center for Community Health Workers (which supports the IMPaCT program at Penn) is fully funded by the University of Pennsylvania Health System. All CHWs and program staff are full-time employees of the health system.

Funding sources for the randomized, controlled trial included the Penn Center for Health Improvement and Patient Safety, the Leonard Davis Institute of Health Economics, the Penn Clinical and Translation Science Community-Based Research Grant, the Eisenberg Scholar Research Award, the Penn Department of Medicine, the Penn Presbyterian Department of Medicine, the Armstrong Founders Award, and the Penn Presbyterian Bach Fund.end fs

Tools and Other Resources

The IMPaCT toolkit, an online platform for data tracking, and other resources are available from the University of Pennsylvania at: http://chw.upenn.edu/tools.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain stakeholder buy-in: Program developers should seek support from health system leaders, physicians, nurses, and residents in low-income communities. They should also enlist the assistance of information technology personnel, who can provide access to data to inform decisions related to which clinical conditions to target and which outcomes to monitor.
  • Recruit the right CHWs: Program success depends in large part on hiring the right people to serve as CHWs. The success of any training effort will be limited if the newly hired individuals do not have the skills and perspectives needed to work effectively with low-income, high-risk populations. (More information on selecting and interviewing CHWs can be found in the IMPaCT toolkit.)
  • Adapt model to local needs: The model should be adapted to the needs of the implementing community. To that end, local organizations should engage their own at-risk populations to determine their areas of need and then modify the program (e.g., CHW job descriptions, training) accordingly.
  • Teach clinicians about CHW role: CHWs are relatively new to the clinical workforce, and clinicians may not understand their scope of work. Managers can provide a link between the CHWs and clinicians by explaining the CHW role and identifying clinical “champions” for them and the program.
  • Pay attention to workflow redesign: In both inpatient and outpatient settings, work with clinicians to determine how to formally incorporate the CHWs and their services into existing workflows and processes.

Sustaining This Innovation

  • Track and share data: Monitoring and regularly sharing data that illustrate the clinical value of the program will ensure that it enjoys ongoing support from institutional leaders, clinicians, and other key stakeholders.
  • Embed CHWs into clinical teams: Embedding CHWs into the clinical teams helps sustain the model over time. By contrast, using a centralized group of CHWs serving all providers would likely reduce referrals to the program, hinder the sharing of clinical information and the development of collegial relationships, and negatively affect the level of patient engagement.
  • Monitor policy developments: Periodically assess strategic and policy options to assess the potential for expanding the scope or reach of CHWs.

Spreading This Innovation

A grant from the Penn Medicine Center for Innovation has enabled the Penn Center for Community Health Workers to build additional capacity for dissemination of the model to other organizations, including development of a free toolkit and an online data tracking platform (which went live in February 2014), and the ability to provide technical assistance to other organizations. To date, approximately 50 organizations have accessed the IMPaCT toolkit and roughly 25 have expressed interest in obtaining technical assistance.

More Information

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Contact the Innovator

Shreya Kangovi, MD, MS
Department of Medicine
University of Pennsylvania Perelman School of Medicine
1233 Blockley Hall
423 Guardian Drive
Philadelphia, PA 19104
kangovi@mail.med.upenn.edu

Innovator Disclosures

Dr. Kangovi reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

The IMPaCT program Web site is available at: http://chw.upenn.edu/.

Kangovi S, Mitra N, Grande D, et al. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern Med. 2014 Feb 10 [Epub ahead of print]. [PubMed]

Footnotes

1 The MacArthur Foundation. Research Network on Socioeconomic Status and Health. January 29, 2012. Available at: http://www.macfound.org/press/info-sheets/socioeconomic-status-and-health-information-sheet/.
2 Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60-76. [PubMed]
3 Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-7. [PubMed]
4 Foraker RE, Rose KM, Suchindran CM, et al. Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization: Atherosclerosis Risk in Communities cohort (1987 to 2004). Circ Heart Fail. 2011;4(3):308-16. Available at: http://circheartfailure.ahajournals.org/content/4/3/308.full. [PubMed]
5 Kangovi S, Mitra N, Grande D, et al. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern Med. 2014 Feb 10 [Epub ahead of print]. [PubMed]
6 Whitley EM, Everhart RM, Wright RA. Measuring return on investment of outreach by community health workers. J Health Care Poor Underserved. 2006;17(1 Suppl):6-15. [PubMed]
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Original publication: August 27, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.