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Managing Multiple Chronic Conditions with a Community Health Worker Intervention

An Evidence-Based Practice

Description

Patients who resided in high-poverty zip codes, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited to join a randomized control trial from 3 primary care facilities in Philadelphia, PA. Participants were randomized to either the Community Health Worker (CHW) intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment.

Goal / Mission

To assess whether an Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers improved patients' chronic disease management and self-rated physical and mental health.

Impact

Individuals with multiple chronic conditions when paired with a community health worker will perceive that their care is higher quality and may have fewer hospitalizations.

Results / Accomplishments

Patients in the CHW group were more likely to report the higher quality of care and spent fewer total days in the hospital at 6 months and 9 months. Among patients who were hospitalized, individuals experienced lower number of hospitalizations and shorter lengths of stay. Lastly, patients who were paired with a CHW had a lower odds of repeat hospitalizations, including 30-day readmissions.

About this Promising Practice

Organization(s)
Penn Center for Community Health Workers
Primary Contact
Penn Center for Community Health Workers, Penn Medicine, Philadelphia, Pennsylvania
215-662-8624
Vera.Jahnle@PennMedicine.upenn.edu
https://chw.upenn.edu/contact/
Topics
Health / Health Care Access & Quality
Organization(s)
Penn Center for Community Health Workers
Date of implementation
2015
Location
Philadelphia, PA
For more details
https://jamanetwork.com/journals/jamainternalmedic...
Target Audience
Older Adults

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An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.
Greater Hampton Roads