Penn's Innovative Community Health Worker Model Improves Outcomes for High-Risk Patients

Experts at the Perelman School of Medicine at the University of Pennsylvania have devised an effective, replicable program using trained lay Community Health Worker (CHWs) to improve a range of outcomes among patients at high risk for poor post-hospital outcomes. In Penn’s IMPaCT (Individualized Management for Patient-Centered Targets) model, CHWs hired from within the local community help patients to navigate the health care system and address key health barriers, such as housing instability or food insecurity. A new study in JAMA Internal Medicine reports that this intervention improved both patient experiences and health outcomes, while reducing repeat hospital readmissions. The authors suggest the results have positive implications for exporting and adapting the CHW model to other patient populations.

“The new health care laws make health systems accountable for patient outcomes like primary care access, quality, and hospital readmissions. To improve these outcomes, it is vital that health systems implement programs that reach beyond their walls and address the root causes of poor health,” said lead study authorShreya Kangovi, MD, MS, assistant professor of Medicine and director of the Penn Center for Community Health Workers. “CHWs have the potential to help tackle these issues. They come from withinhigh-risk communities, can relate to patients, are able to help breach potential breakdowns in communication between patients and their care providers, and address the socioeconomic and behavioral factors that affect health.”

Historically, many intervention programs have been difficult to replicate and lacked rigorous scientific evaluation. With these specific issues in mind, the Penn team tested the IMPaCT model in a randomized trial with 446 hospitalized patients who were either uninsured or on Medicaid, and resided in low-income communities in which more than 30 percent live below the Federal Poverty Level. More than one-third of all readmissions to the hospitals participating in the study come from this five-ZIP code region.