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

Posted on

A recent study found that an innovative peer support program improves access to care and quality of communication while reducing repeat hospitalizations, which can reduce costs. Experts at the Perelman School of Medicine at the University of Pennsylvania have developed an effective and innovative program using trained lay community health workers 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, local community health workers help patients to navigate the health care system and address key health barriers, such as housing instability or food insecurity. A new study in the Journal of the American Medical Association Internal Medicine reports that this intervention improved both patient experiences and health outcomes, while reducing repeat hospital readmissions, thereby lowering costs.

“Community health workers have the potential to help tackle these issues. They come from within high-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,” said lead study author Shreya Kangovi, MD, MS, assistant professor of Medicine and director of the Penn Center for Community Health Workers.

The community health workers connect during a patient’s hospital stay and continue to partner with patients after they are discharged, helping to overcome barriers or issues such as scheduling doctor appointments, accessing medications, or finding child care or shelter.

Results of the study show that those individuals who worked with the community health workers were 52 percent more likely to see a primary care physician within two weeks after being discharged from the hospital. In addition, these individuals were more confident in managing their own care, reported better discharge communication, showed improvement in self-rated mental health scores, and were less likely to have multiple readmissions. And community health workers, who are often paid much less than doctors and nurses, offer a cost-effective way of reducing repeat hospital and emergency room visits, as well as improving preventative care management and long term health and wellness outcomes.