Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients | AHRQ Innovations Exchange

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Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients | AHRQ Innovations Exchange

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients

Snapshot

Summary The 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. Evidence Rating (What is this?) 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 Organizations University of Pennsylvania Health System Date First Implemented 2011 Patient Population Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Insurance Status > Uninsured

August 27, 2014 Issue
Enhancing Primary Care Access and Capacity

This issue includes

Innovations:

• Community Health Workers on Clinical Teams Enhance Access for Low-Income Patients

Contact the Innovator

Shreya Kangovi, MD, MS