Model Uses Non-Healthcare Workers to Improve Outcomes in Patients with Chronic Diseases


Jill Feldstein, MPA, chief operating officer for the Penn Center for Community Health Workers, tells Managed Healthcare Executive how the organization improves population health and provides social support, advocacy, and navigation to high-risk patients.



Nearly one in three people in the U.S. have multiple chronic conditions, accounting for more than 65% of all healthcare spending. Low-income and minority individuals are more likely to have multiple chronic conditions and worse health outcomes than their more advantaged counterparts, according to a recent study.

To provide high-value care, more and more healthcare organizations are attempting to reach outside their hospital and clinic walls to address ‘upstream’ social factors such as trauma, food insecurity, and homelessness that are at the root of poor health for many low-income patients.

The Penn Center for Community Health Workers, a national organization dedicated to community health worker (CHW) research, patient care, and dissemination, trains laypeople who share life experience with high-risk patients to assist with outreach to these patients through its  IMPaCT (Individualized Management for Patient-Centered Targets) model.

The Center started by interviewing hundreds of low-income patients to understand what would help them focus on or improve their health. With their input, the IMPaCT model was designed, which has served more than 7,000 patients to date in the Philadelphia area, including patients at Penn Medicine, the Crescenz Veterans Affairs Medical Center, and members of Keystone First, the largest managed care provider in southeastern Pennsylvania.

In the model, trained laypeople provide social support, advocacy, and navigation to high-risk patients. They do things with patients that nurses, doctors, and social workers do not do. For example, they exercise with patients at a local gym, reconnect them with estranged family members, or sing with their patients in a local church choir.

The model has been tested in three randomized controlled trials, two of which have been published. Results include:

“The challenge of how to improve population health across the Triple Aim for the nation’s most vulnerable patients has grown over the years and remains one of our country’s biggest issues. We have created an adaptable, scalable model that can cost effectively improve these outcomes for high-risk, low-income populations,” says Jill Feldstein, MPA, chief operating officer for the Penn Center for Community Health Workers.

“Economic analysis shows that the IMPaCT intervention has a $2:1 annual return on investment. Overall, as healthcare moves toward shared-risk models, payers, providers, and state Medicaid offices are seeking models that help them achieve better health outcomes, more cost effectively.”

The Center has also developed standardized tools, training and technical assistance for healthcare organizations across the country looking to start or improve CHW programs.

“As one example, we developed hiring practices to effectively screen for traits like empathy,” Feldstein says. “As a result, while typical CHW programs see turnover rates of 50% to 77%, we’ve had 1.7% turnover in the past seven years.” 

Today, the Center for Community Health Workers employs more than 50 individuals working in three main areas. “We conduct cutting-edge research on effective CHW programs; we deliver IMPaCT to more than 2,000 patients in Philadelphia each year; and we provide tools, training and technical assistance to organizations across the country, including the University of Pittsburgh Medical Center Health Plan and the Department of Health for the State of Louisiana,” Feldstein says.

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