Patients stay healthier with peer support
At-risk patients benefit from CHWs
Over the past four years, more than 3,000 at-risk patients treated by providers in the University of Pennsylvania Health System have received consistent primary care, improving their health and avoiding hospitalizations and readmissions with the support of community health workers, trained laypersons who live in the community and understand the challenges the patients face.
"These patients have a lot of barriers to staying healthy, including economic and psychosocial issues such as unstable housing, unstable access to food, and lack of transportation," says Casey Chanton, MSW, project manager for the Penn Center for Community Health Workers. "Community health workers are trained lay people, not clinicians, and their role is one of support, advocacy, and navigation. Because they have had some of the same life experiences, patients feel comfortable talking with the community health worker."
A team of researchers at the Perelman School of Medicine at the University of Pennsylvania developed the IMPaCT (Individualized Management for Patient-Centered Targets) model after interviewing more than 100 high-risk patients about their challenges in receiving healthcare and staying healthy and reviewing other community health worker programs.
"A major theme of the interviews was a sense of disconnect from the traditional healthcare staff. The patients told us that the doctors and nurses were from very different backgrounds and didn’t understand the world the patients live in. The providers often gave patients health goals that they couldn’t possibly meet due to their living situation or other social and economic barriers," Chanton says.
Based on what the patients had told them, the team developed a model of care that uses lay people within the community to work with at-risk patients. "Our community health workers share characteristics with the patients they serve. They live in the same neighborhoods, share race and culture, and have had the same life experiences," he says.
The team conducted a pilot randomized control trial with 446 patients and determined that in just two weeks, the IMPaCT model significantly improved patient activation, access to primary care, mental health status, communication scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and recurrent readmissions.
The health system created the Penn Center for Community Health Workers and adapted the IMPaCT model for the inpatient hospital and clinic setting.
The community health workers meet patients in the hospital or the clinic, visit them at home, and accompany them to clinic visits or community social service agencies. "They serve as a bridge between the healthcare team and the patient," Chanton says.
The community health workers have the time and patience to listen to patients and find out what is going on in their lives. "Many of the issues that make it difficult for patients to stay healthy are not medical issues but are real-life issues such as unstable housing or lack of transportation," he says.
The community health workers ask the patients what they need to do to improve their own health and work with them in meeting healthcare goals, Chanton says. They may help them find childcare, look for a job, or sign up for food stamps.
The community health workers collaborate with clinicians on the treatment team to identify patients who could benefit from the intervention. Community health workers embedded in the hospital setting work on transitions between the hospital and the community and follow patients closely for a minimum of two weeks after discharge, he says.
The health workers meet patients while they are still in the hospital and talk with them about their health issues and what they need to do to get healthy, Chanton says. They may help patients identify a primary care provider and accompany them to their appointment. They work with patients on meeting their healthcare goals and help them access any community resources they need. Because of the intensity of the interventions, hospital-based community health workers carry a caseload of only eight to 12 patients at a time, he says.
Community health workers in the clinic setting have a caseload of 25 to 30 patients and work closely with them for six months, meeting them when they come to the clinic and working with them in person in the community, he says.
"Patients meet with their providers to set healthcare goals. The community health workers help the patients break these goals down into achievable steps, create an action plan, then support them as they meet those goals," Chanton adds.
The community health workers round with the clinical team and often are able to provide useful psychosocial or socioeconomic information that the providers otherwise wouldn’t know.
"They visit in the home and see what the conditions and family situation are like. They can give the team a fuller sense of everything that is going on in the patient’s life. Because they develop close relationships, patients may share information with the community health worker that they are reluctant to tell their physicians," he says.
Patients targeted for IMPaCT interventions live in five ZIP codes with high rates of poverty where residents are at highest risk for readmissions and chronic diseases. The Penn Center recruits community health worker candidates from the same geographic area.
"We partner with community organizations to help in our recruiting. Our goal is to hire people who are natural helpers in the community. Many of them are already doing similar work, like checking on a sick neighbor," Chanton says.
The community health workers go through four weeks of training that includes peer counseling for behavioral change, how to access resources in the community, how to interact with a medical team, and how to work with patients who are in crisis or facing health issues and help them access the appropriate providers.
The Penn Center for Community Health Workers has developed a tool kit that other providers may use to implement a community health workers program. The tool kit is available at no charge at http://chw.upenn.edu.