Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: a Randomized Clinical Trial
To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions.
We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences.
Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. CONCLUSIONS:
A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for healthcare systems.
Overview of article
- In a high-risk population of disadvantaged patients with multiple chronic diseases, a community health worker (CHW) intervention combined with collaborative goal-setting led to modest improvements in diabetes, obesity, and smoking, but not in hypertension, compared with collaborative goal-setting alone
- The CHW support also improved mental health and quality of primary care and appeared to reduce hospital admissions
- In the study intervention, CHWs did not provide disease education or clinical care, yet the patients in the CHW group had improved clinical outcomes. This adds to the body of literature underscoring the importance of addressing social and behavioral determinants of health
Methods of article
- This study conducted a single-blind, randomized clinical trial in Philadelphia, PA (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences
- This has practical implications for health system leaders who are interested in moving from disease-specific interventions to population health interventions that can influence outcomes across multiple conditions. Currently, health systems and primary care practices with limited resources are often forced to choose between disease-specific interventions. These fragmented interventions can be confusing for patients and paradoxically make navigating the health system even more challenging
- Cumulative reductions in hospitalization from this and a previous randomized controlled trial have been used by the University of Pennsylvania Health System analytics department to estimate a return on investment of $2 for every dollar invested in the IMPaCT intervention. These findings led the University of Pennsylvania Health System to adopt the intervention as part of its system-wide population health management strategy for high-risk, socially disadvantaged patients. The intervention has been delivered to 6000 patients and adapted for use across different care settings including a Veterans Affairs Medical Center, a federally qualified health center, a large academic medical center, and an integrated payer–provider network
- Limitations: 1) Patients with hypertension were relatively well-controlled at baseline; 2) This was a single-center study among patients in severely resource-limited settings; 3) Relatively small number of noncompleters; and 4) Both study arms were active comparators so they could not assess effectiveness compared with usual care