The IMPaCT (Individualized Management of Patient-Centered Targets) model is a standardized, scalable, evidence-based Community Health Worker (CHW) intervention proven to improve chronic disease control, quality of care, mental health, and access to primary care while reducing costly hospitalizations.
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Penn Center for Community Health Workers (PCCHW)
- Academic Medical Center
- Community health center
- The shift towards value-based alternative payment models has changed the business of healthcare. The new business model requires healthcare organizations to address not only medical problems, but real-life problems like hunger, loneliness and trauma. That’s because these types of issues, otherwise known as the social determinants of health, are key drivers of the outcomes healthcare organizations are now incentivized to achieve.
- Many healthcare organizations are looking to CHWs, trusted laypeople who come from within low-income communities, to help support patients in addressing the social determinants of health. Some state Medicaid programs even require that CHWs are included in Patient-Centered Medical Homes and Accountable Care Organizations. For example, in Connecticut, ACOs that participate in the Medicaid Shared Savings Program are required to utilize CHWs.
- While the concept of CHWs is exciting, the reality is that these programs often fail because of high turnover, lack of standardized infrastructure, and insufficient evaluation.
- In 2010, the same factors that were playing out on the national stage were occurring at Penn Medicine.
- The Affordable Care Act held health systems accountable for patient outcomes, such as primary care access, patient-reported quality of care, and hospital readmission. Low-income people are at highest risk by these measures.
- Therefore, it was both a patient care and financial imperative for Penn Medicine to improve outcomes for these vulnerable patients.
Patient Population Served and Payor Information
- The Penn Center for CHWs has directly served nearly 10,000 low-income patients in the Philadelphia region across all diagnoses, ages, and care settings.
- Similarly, healthcare organizations throughout the country that have adopted the IMPaCT model apply it to high-risk patients across a range of demographic criteria.
- Shreya Kangovi, MD, MS: Dr. Kangovi is the Founding Executive Director of PCCHW and a leading expert on improving population health through community health workers. Dr. Kangovi designed the IMPaCT model and has authored numerous scientific publications in the New England Journal of Medicine, JAMA and Health Affairs, among others.
- Tamala Carter: Ms. Carter is a Community-Based Research Coordinator at PCCHW. She has conducted more than 400 hundred in-depth interviews with lower-income patients and co-authored several publications detailing her findings. Her original patient interviews were used to design the IMPaCT model.
- Jill Feldstein, MPA: Ms. Feldstein is the Chief Operating Officer of PCCHW and previously served as the inaugural director of the organization. She grew the Center from 5 to 50 FTEs and oversaw the growth of the program to new hospital and health systems. In her role as COO, Ms. Feldstein leads all aspects of implementation support to our partner organizations.
- Olenga Anabui, MBA, MPH: Ms. Anabui is the Director of PCCHW’s Philadelphia operations. She ensures strategic alignment of the program with health system goals, and oversight hiring, management, and quality of CHW programs.
- Scott Tornek, MBA: Mr. Tornek is the Chief Strategy Officer of PCCHW. He has helped companies and investors launch and scale new products, services and businesses in a wide array of industries, and works with our partner organizations on their CHW business model.
- Initial funding to develop the model came from internal University of Pennsylvania research and health care innovation grants.
- Dr. Kangovi has received over $20 million in funding to support her work in developing and testing this the IMPaCT model of care, including contracts from large academic medical centers, payers and grants from NIH and PCORI.
Research + Planning
- This work began by interviewing 1,500 low-income patients on porches, in shelters and at hospital bedsides. Patients were asked: What makes it hard for you to stay healthy? What should healthcare organizations be doing to help? Clinical personnel such as doctors, nurses, social workers, medical assistants and schedulers were also interviewed. These clinicians were asked clinicians how a program should be designed so that it was helpful to them, rather than being disruptive of their workflows and roles. All of these interviews were used to design the IMPaCT model, so that it was in a sense, pre-approved by the individuals it was designed to benefit.
- Testing of the model, including three clinical trials, has demonstrated that IMPaCT improves outcomes such as mental health, access to care and chronic disease control, while reducing hospital use. The most recent multi-center trial RCT, including a Veterans Affairs medical center, federally-qualified health center and academic center, reveals a reduction in hospital days of 65%. The results translate to a $2 return for every $1 invested, based on improvements in chronic disease outcomes and reductions in admissions.
- Organizations that are partnering with PCCHW across the country are aided in engaging local stakeholders so that the model is adapted to their needs and preferences.
- While the IMPaCT model is flexible, it works best if it is implemented using four key roles which help to create a robust program infrastructure:
- CHWs: natural helpers hired from the communities served who work directly with patients to set and achieve goals that enable patients to improve their health.
- Managers: typically social workers who supervise CHWs, ensuring effective patient care and integration with health care teams.
- Coordinators: individuals who identify and enroll eligible patients, and collect and report on data to evaluate the program.
- Directors: leaders who oversee hiring, budgets, and quality of the CHW program.
Tools or Products Developed
- Work practice manuals, college-accredited in-person and online training, and software to support this intervention have been developed. These are explained in detail here.
- PCCHW has developed college-accredited in-person and online training for CHWs, supervisors, and program directors designed to build, maintain, and grow successful CHW programs.
- CHW training: Training for CHWs includes two to four weeks of training on critical topics, including working effectively with medical providers, supporting patients with psychiatric concerns, and de-escalating conflict.
- Supervisor training: The three-day supervisor training provides managers with the tools and skills they need to supervise patient care, ensure quality outcomes, and improve CHW performance.
- Leadership training: One day of executive education equips leaders with the tools to hire, develop and retain staff, as well as the skills to achieve and sustain robust outcomes.
- This training is supplemented by core competency certification checkpoints of each of the roles described above, as well as IMPaCT Online, our ever-growing online library of CHW best practices for professional development. This is part of IMPaCT’s technical assistance support.
Team Members Involved
- Community Health Worker
- Social Worker
- To allow for connection at the point of care, patients are identified via EHR using pre-determined eligibility criteria and assigned to ‘on-call’ CHWs embedded in hospital or outpatient care teams.
- Eligibility criteria include living in a hotspot zip code, insurance status (uninsured, Medicaid or dually eligible), and having a medical risk factor.
- CHWs offer IMPaCT services to eligible patients at their clinical site.
- Once a patient accepts services, CHWs work with patients through three stages:
- Setting goals: In the first phase of the IMPaCT model, CHWs use an in-depth semi-structured interview to get to know patients and collaboratively set goals. This process beings with a key question: “What do you think you will need in order to stay healthy?” and leads to goals that are tailored to individual patient needs and major determinants of health concerns, referred to as the “root causes” (examples below):
- Providing tailored support: In the second stage of IMPaCT, CHWs provide tailored, unique, and outside-of-the-box support to patients, meeting them at home/community visits to get things done together. CHWs leverage patient, family, and grassroots resources to address the wide range of root causes of patients’ poor health, which often extend beyond lack of resources to issues like social isolation and low self-esteem. They can jump-start motivation by exercising with patients at the local gym, relieve stress and isolation by facilitating conversations between estranged family members, and restore joy for traumatized patients through fun activities such as bowling.
- Connecting to long-term support: The third phase of IMPaCT is to ensure participants have connection with a source of long-term support. This ranges from church to case management and includes a weekly peer support group facilitated by CHWs. Ensuring these long-term supports are in place helps avoid the ‘voltage drop’ that often accompanies the end of an intensive intervention and helps explain the persistence effect seen in the IMPaCT model.
- Managers meet with CHWs weekly to review patient cases and help CHWs prioritize/troubleshoot. Managers also conduct weekly quality reviews (e.g. calling patients, reviewing outcome measures, etc) to ensure fidelity and strong outcomes.
- The cost to deliver intensive IMPaCT CHW support is $1,250/patient, less than the average cost of a single night in the hospital.
Where We Are
- This work began in 2010 and has continued to grow over the years since.
- The IMPaCT model was assessed through three clinical trials published in JAMA and the American Journal of Public Health. These trials consistently demonstrate improvement in outcomes:
- Mental health: self-rated mental health (12-item Short Form survey)
- Intervention (IMPaCT) patients compared to controls showed greater improvements in mental health (6.7 vs. 4.5; P = 0.02).
- Chronic disease control: changes in HbA1c, systolic blood pressure, smoking rates, obesity rates
- CHW support led to improvements in HbA1c (-0.4 vs. 0.0), body mass index (-0.3 vs. -0.1), cigarettes per day (-5.5 vs -1.3), systolic blood pressure (-1.8 vs. -11.2; overall P = 0.08).
- Access to primary care:
- Intervention (IMPaCT) patients compared to controls were more likely to obtain timely post-hospital primary care (60.0% vs. 47.9%; P = 0.02).
- Patient-reported quality of care: based on Consumer Assessment of Healthcare Providers and Systems
- Intervention (IMPaCT) patients compared to controls were more likely to report the highest quality of care (OR 1.8; 95% CI 1.4-2.4; P <0.001).
- Hospitalizations: number of hospitalizations
- Intervention (IMPaCT) patients compared to controls were more likely to have less hospitalizations (difference, -0.3; 95% CI -0.6 to 0.0; P = 0.07) and had a lower odds of repeat hospitalizations (OR 0.4; 95% CI 0.2-0.9; P = 0.02).
- Mental health: self-rated mental health (12-item Short Form survey)
- From 2019-2021, PCCHW plans to test the efficacy of implementing IMPaCT across three states, measuring:
- Reach: the number of people receiving support from an IMPaCT CHW
- Staff fidelity to intervention processes
- Stage of implementation achieved: measured by the SIC score, a validated theory-based measure that predicts variations in implementation behavior
- All-cause hospitalizations: will compare patients receiving IMPaCT with matched control patients
- With funding from the Commonwealth Foundation, PCCHW is currently testing a combined CHW/digital financial incentives approach to see if this hybrid intervention improves control of diabetes among Medicaid patients. CHWs will support patients who struggle with glucose monitoring by helping them to address underlying socioeconomic barriers and cope effectively with setbacks. This project will conclude in July 2020.
- As shown in three clinical trials, IMPaCT improves critical outcomes including chronic disease control, quality of care, mental health, and access to primary care while reducing costly hospitalizations.
- The IMPaCT model gains efficiencies by centralized supervision and infrastructure. However, running a centralized program in a decentralized health system requires strong communication processes with individual clinical entities and health system leadership to ensure connection to both strategic objectives and local priorities.
- Community Health Workers (CHWs): trained laypeople who are “natural helpers” hired from the communities they serve to provide health care navigation, resource connection, and social support to patients.
- Written with significant input from Shreya Kangovi and Jill Feldstein.
- Kangovi, S., Mitra, N., Norton, L., Harte, R., Zhao, X., Carter, T., Grande, D. and Long, J.A., 2018. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: a randomized clinical trial. JAMA Internal Medicine, 178(12), 1635-1643.
- Kangovi S, Asch DA, 2018. The Community Health Worker Boom. NEJM Catalyst. Retrieved from http://catalyst.nejm.org/community-health-workers-boom/.
- Kangovi, S., Mitra, N., Grande, D., Huo, H., Smith, R.A. and Long, J.A., 2017. Community health worker support for disadvantaged patients with multiple chronic diseases: a randomized clinical trial. American Journal of Public Health, 107(10),1660-1667.
- Kangovi, S., Carter, T., Charles, D., Smith, R.A., Glanz, K., Long, J.A. and Grande, D., 2016. Toward a scalable, patient-centered community health worker model: adapting the IMPaCT intervention for use in the outpatient setting. Population Health Management, 19(6), 380-388.
- Kangovi, S., Mitra, N., Grande, D., White, M.L., McCollum, S., Sellman, J., Shannon, R.P. and Long, J.A., 2014. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Internal Medicine, 174(4) 535-543.
- Kangovi, S., Grande, D., Carter, T., Barg, F.K., Rogers, M., Glanz, K., Shannon, R. and Long, J.A., 2014, July. The use of participatory action research to design a patient-centered community health worker care transitions intervention. Healthcare 2(2); 136-144).
- Shreya Kangovi, MD, MS
- Scott Tornek, MBA
- Olenga Anabui, MBA, MPH
- Jill Feldstein, MPA
- Tamala Carter
Philadelphia, PATalk to the Innovators