Patient-Centered Community Health Worker Intervention to Improve Post-hospital Outcomes
An Evidence-Based Practice
Description
The Individualized Management for Patient-Centered Targets (IMPaCT) program employed CHWs to support patients for 2 weeks following hospital discharge in setting and achieving goals, including connecting with long-term supports to address socioeconomic and behavioral barriers to their attainment.
Goal / Mission
The Goal of this Promising Practice is to determine whether a tailored community health worker (CHW) intervention would improve post-hospital outcomes among low-SES patients.
Impact
This intervention would improve access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population. Health systems may leverage the CHW workforce to improve post-hospital outcomes by addressing behavioral and socioeconomic drivers of disease.
Results / Accomplishments
Intervention patients were more likely to obtain timely post-hospital primary care (60.0% vs 47.9%; P = .02; adjusted OR=1.52; 95% CI, 1.03-2.23), to report high-quality discharge communication (91.3% vs 78.7%; P = .002; adjusted OR, 2.94; 95% CI, 1.5-5.8), and to show greater improvements in mental health (6.7 vs 4.5; P = .02) and patient activation (3.4 vs 1.6; P = .05). There were no significant differences between groups in physical health, satisfaction with medical care, or medication adherence. Post-discharge patients in the CHW group were equally likely to be readmitted but were less likely to have multiple readmissions (2.3% vs. 5.5%) as those in a control group. Among 63 patients who were readmitted, recurrent readmission was reduced from 40.0% to 15.2%.
About this Promising Practice
Organization(s)
University of Pennsylvania
Topics
Health / Health Care Access & Quality
Organization(s)
University of Pennsylvania
Date of publication
Apr 2014
For more details
Additional Audience
Low-income individuals
Submitted By
Conduent Healthy Communities Institute