Study adapts proven community health worker model for outpatient setting

In the Individualized Management for Patient-Centered Targets, or IMPaCT™ model, CHWs visit patients facing multiple chronic conditions and help in navigating the health care system and carrying out daily activities. CHWs come from low-income communities and provide social support to address the real-life issues -- hunger, homelessness, transportation barriers, etc. -- that make it hard to stay healthy.

In the current study, lead author Shreya Kangovi, MD, MS, an assistant professor of Medicine and executive director of the Penn Center for Community Health Workers, and senior author David Grande, MD, MPA, an assistant professor of Medicine, and Penn colleagues, including IMPaCT community health workers, conducted qualitative in-depth interviews with 21 chronically ill, uninsured, or Medicaid outpatients from low-income zip codes as well as 30 members of their primary care practice staff. Using the responses to these interviews, the researchers created an outpatient manual to administer IMPaCT outside of the hospital setting, hired additional staff, and are working with seven primary care facilities in Philadelphia to implement IMPaCT on their premises, including the Corporal Michael J. Crescenz VA Medical Center and a federally qualified health center.

IMPaCT has been adopted by the University of Pennsylvania Health System as part of routine care for over 5,000 patients. Recruitment, training, care, and integration systems within the program were established with input from hundreds of patient interviews to address challenges routinely faced.

"IMPaCT has been successfully used for several years throughout the Penn health system," said Kangovi. "We've seen several positive results, including reduced readmission rates and better health outcomes. We wanted to introduce new patients who had not yet been hospitalized to the model, so our study is helping us adapt it to the outpatient setting."

Under the IMPaCT approach, neighborhood residents are recruited and trained as community health workers. The workers join patients and their providers to set achievable health goals. They next help patients to create tailored plans and support patients in achieving those goals. Activities could include exercising with patients at the local YMCA, helping to coordinate doctor's appointments, and providing emotional support through a difficult time. The community health workers then link patients with a long-term source of support -like stable primary care or a support group that the CHWs facilitate--in order to maintain their health gains and prevent future problems.

The Penn researchers identified three themes that helped them adapt the original IMPaCT model for the outpatient setting.

First, outpatients were overwhelmed by their multiple health conditions and wanted to concentrate on one at a time. To address this finding, design mapping was used to create a low-literacy decision aid called the Goal Card, which allows patients to select one of their chronic conditions to focus on. Second, motivation for health behavior change was a more prominent theme than in the hospital-based version. It was therefore decided that in addition to providing tailored social support as in the original approach, community health workers would help patients track progress toward their chronic disease management goals to motivate health behavior change. Third, patients were already connected to primary care; yet they still needed additional support to navigate their clinic once the intervention ended. The intervention was revised to include a weekly clinic-based support group.

"Our findings are relevant to the growing interest in community health worker programs across the United States," said Grande, who is also a senior fellow in the Leonard Davis Institute of Health Economics at Penn. "But many payers and provider organizations are tempted to use a trial-and-error approach. This results in a lot of reinventing the wheel, which is costly, time-consuming, and leaves programs open to making common mistakes. And many of these efforts lack formal evaluation. On the other hand, we know that one size doesn't always fit all, so we didn't want to be too rigid about fidelity without allowing for adaptation and tailoring. Our study describes a way to balance fidelity and fit."

The center is using the methodology described in this paper to adapt the IMPaCT model for use in new health systems and geographic settings as part of its new Partnership Program. This program helps partner organizations to adapt IMPaCT manuals to suit the needs of local populations, and then provides turn-key support for program launch, including hiring, training, documentation, clinical integration and evaluation.