EXECUTIVE SUMMARY

After a randomized trial showed that patients receiving interventions from a community health worker had improved outcomes, Penn Medicine expanded the program and now 30 community health workers are embedded on teams in hospitals and primary care clinics.

  • Health system researchers interviewed hundreds of patients about the roadblocks to receiving care and how community health workers could help, and developed the Individualized Management for Patient-Centered Targets (IMPaCT) model.
  • Community health workers are referred by hospital staff or primary care providers and work with patients for specific lengths of time depending on the patient needs.
  • They go into the community and meet with patients in their homes, often identifying nonmedical issues that need to be handled before patients can concentrate on their health.

Patients who received interventions from a community health worker (CHW) experienced an increase in access to a primary care provider and a reduction in readmissions during a randomized trial conducted by researchers at Penn Medicine.

The two-week trial included 446 patients, half of whom received support from a community health worker and half who did not. The intervention group reported an increased level of patient engagement, and gave their providers higher scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Based on the success of the trial, the health system invested in growing the program and now 30 community health workers are embedded on teams in the hospital setting and in the health system’s primary care clinics, and work with 2,000 patients every year, reports Jill Feldstein, MPA, chief operating officer for the Penn Center for Community Health Workers, which is part of the Philadelphia-based health system.

The health system developed the Individualized Management for Patient-Centered Targets (IMPaCT) model based on input from hundreds of patients. Patients are identified for the program based on information in the medical record, by treatment team members who identify patients who need help with transitions, and by primary care physicians who refer patients who need assistance with managing one or more chronic conditions.

The community health workers work with patients for specific amounts of time, depending on the patients’ conditions and needs.

The CHWs in the hospital program work with patients for two to four weeks, helping ensure a safe transition from hospital to home and reconnecting with a primary care provider. When hospitalized patients need more support, the CHW follows them for three months. Patients who need help changing their habits to improve chronic health conditions receive support for six months.

If patients are identified for the program while they are in the hospital, the CHW visits, explains the program, and enrolls the patients if they are interested.

When patients have chronic health conditions, a member of the IMPaCT team calls them before their clinic visits, describes the program, and arranges for a CHW to meet with patients at the clinic if they agree to participate.

“We inform the patients of the defined duration of the program at the time they enroll. It gives patients an incentive to work harder when they know how long they will have support from the community health worker, and it helps us manage the caseloads of the CHW,” Feldstein says.

During their initial meeting at the hospital or the clinic, the community health workers spend time with patients, getting to know them and building rapport. They have a lengthy conversation that covers social issues as well as medical issues and helps the CHW identify the patients’ support systems and barriers to taking care of their health.

“At the end of the interview, they walk out with a game plan based on each patient’s individual needs and wishes,” Feldstein says.

Each individual care plan centers around what the patient wants, Feldstein says. “The community health workers take time to get to know the patients and their goals, which increases buy-in. Sometimes, other people on the care team may tell the patient what they should do. This program turns that around and asks the patient what they want to focus on,” she says.

Many times, the CHWs identify nonmedical issues that need to be addressed before the patients can concentrate on their health.

For instance, one woman in the program was in and out of the hospital with out-of-control blood sugar. The CHW determined that the patient was focused on the needs of her autistic child and wasn’t taking care of herself.

The CHW visited the child’s school and identified support services for autistic children. He set an alert on the patient’s cellphone to reminder her to take her medication.

“The initial conversation revealed two problems that the CHW was able to solve by getting extra support for the child and setting up a simple alert,” Feldstein says.

A patient referred to the CHW program by her primary care provider set a goal of losing weight, but during the conversation, she reported that one of the major stressors in her life was trying to find new housing so she could move out of her unsafe home.

When the CHW learned that the patient had been a basketball player in high school, he suggested they play weekly pickup games at a basketball court in her neighborhood. He brought along his laptop and cellphone and researched potential places to live, then helped the patient fill out housing applications after the game.

“The community health workers get things done in the moment to show people they are serious about helping them,” Feldstein says.

The CHWs often follow up with patients by phone, but a core part of their job is going into the community and engaging with patients, she says. They have work space in the hospitals and the primary care clinics, but they spend most of their time in the community, at patients’ homes, at the senior center, or wherever they need to go to support the patient.

“Community health workers go where they need to go and get done what needs to be done. Going into the home and meeting people where they are is an important part of the program,” Feldstein says.

Caseloads for the community health workers range from 10 to 30 patients, depending on the patient needs and the setting. “In general, their caseloads are smaller than the licensed staff and they can devote more time to the patients’ concerns,” she says.

The program is designed so that the CHWs are part of the care team in both the hospital and the primary care setting. They communicate regularly with the nurses, physicians, case managers, and other clinicians.

In hospitals, CHWs participate in the care team activities in the best way for each team. They attend morning rounds or daily huddles with some teams, and with others communicate mostly through the medical record. In the clinics, CHWs may meet with the entire team on a regular basis, or have one-on-one meetings with the physicians to discuss individual patients.