SummaryThe University of Pennsylvania Health System embeds community health workers into its clinical teams at hospitals and medical offices. Following the Individualized Management for Patient-Centered Targets (more commonly referred to as IMPaCT) model, the community health workers provide low-income patients with emotional support and help them navigate the health system and obtain appropriate care and community-based services and support. In the inpatient setting, they provide support both in the hospital and for at least 14 days after discharge, while in the outpatient setting they support chronically ill patients for 6 months. In both settings, they work with patients to develop goals and related action plans and provide customized support, including connections to needed services. In a randomized trial at two academic medical centers, the inpatient component of the IMPaCT model improved discharge-related communication, enhanced access to postdischarge primary care, and increased levels of patient activation, leading to fewer readmissions and depression-related symptoms and to positive feedback from patients.Strong: The evidence consists primarily of a randomized, controlled trial that compared key metrics among those participating in the inpatient component of the program with a similar group of patients who did not. Metrics include patient assessments of the quality of discharge-related communications, likelihood of accessing postdischarge primary care, 30-day readmission rates, depression symptoms, and levels of patient activation.
Developing OrganizationsUniversity of Pennsylvania Health System
Date First Implemented2011
Patient PopulationVulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Insurance Status > Uninsured
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