Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial

Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, Shannon RP, Long JA
Source: JAMA Intern Med
Publication Year: 2014
Patient Need Addressed: Patient satisfaction/engagement
Population Focus: Low income, Medicaid beneficiaries, Uninsured
Intervention Type: Staff design and care management
Study Design: Randomized Controlled Trial (RCT)
Type of Literature: White
link: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1828743
Abstract

IMPORTANCE: 
Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors.

OBJECTIVE:
To determine whether a tailored community health worker (CHW) intervention would improve posthospital outcomes among low-SES patients.

DESIGN, SETTING, PARTICIPANTS: 
A 2-armed, single-blind, randomized clinical trial was conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. Of 683 eligible general medical inpatients (ie, low-income, uninsured, or Medicaid) that we screened, 237 individuals (34.7%) declined to participate. The remaining 446 patients (65.3%) were enrolled and randomly assigned to study arms. Nearly equal %ages of control and intervention group patients completed the follow-up interview (86.6% vs 86.9%). 

INTERVENTIONS:
During hospital admission, CHWs worked with patients to create individualized action plans for achieving patients’ stated goals for recovery. The CHWs provided support tailored to patient goals for a minimum of 2 weeks.

MAIN OUTCOMES AND MEASURES: 
The prespecified primary outcome was completion of primary care follow-up within 14 days of discharge. Prespecified secondary outcomes were quality of discharge communication, self-rated health, satisfaction, patient activation, medication adherence, and 30-day readmission rates.

RESULTS:
Using intention-to-treat analysis, we found that intervention patients were more likely to obtain timely posthospital primary care (60.0% vs 47.9%; P = .02; adjusted odds ratio [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. Similar proportions of patients in both arms experienced at least one 30-day readmission; however, intervention patients were less likely to have multiple 30-day readmissions (2.3% vs 5.5%; P = .08; adjusted OR, 0.40; 95% CI, 0.14-1.06). Among the subgroup of 63 readmitted patients, recurrent readmission was reduced from 40.0% vs 15.2% (P = .03; adjusted OR, 0.27; 95% CI, 0.08-0.89).

CONCLUSIONS AND RELEVANCE:
Patient-centered CHW intervention improves 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 posthospital outcomes by addressing behavioral and socioeconomic drivers of disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01346462.

Insights Results

Overview of model/article

  • Community Health Workers (CHW)s used motivational interviewing skills to help patients set recovery goals and helped patients create an individualized action plan to achieve these goals. During hospitalization, CHWs served as a liaison between the patients and inpatient care team and provided tailor support based on patients goals using telephone calls, texts, and in-person visits. CHWs encouraged patients to visit with their primary care provider (PCP) post-discharge. If the patient didn’t identify a PCP, the CHW helped find one
  • CHWs were supervised by a master’s level social worker who met biweekly with each CHW and reviewed documents and action plans
  • Researchers developed a CHW model (Individualized Management for Patient-Centered Targets or IMPaCT). IMPaCT was conducted at 2 University of Pennsylvania hospitals. It consists of 3 elements: 1) Recruitment and hiring (guidelines for hiring CHWs); 2) Training (providing a college-accredited 1-momth course to CHWs), and 3) Standardized protocols (goal setting, goal support, and connection to primary care)

    Methods of article

    •  This was a 2-armed, single-blind, randomized clinical trial conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. Of 683 eligible general medical inpatients (i.e., low-income, uninsured, or Medicaid) that we screened, 237 individuals (34.7%) declined to participate. The remaining 446 patients (65.3%) were enrolled and randomly assigned to study arms. Nearly equal percentages of control and intervention group patients completed the follow-up interview (86.6% vs 86.9%)

    Results

    • 446 patients were enrolled. A greater percentage of patients in the intervention arm completed post-hospital primary care follow-up within 14 days of discharge compared with the control arm (60.0% vs 47.9%; P = .02). After adjustment, intervention patients had 52% higher odds for posthospital primary care follow-up within 14 days. Patients in the intervention arm were more likely to report high-quality verbal discharge communication (91.3% vs 78.7%; P = .002) and greater improvements in mental health (mean, 6.7 vs 4.5; P = .02) and activation (3.4 vs 1.6; P = .05). There were no significant differences between the intervention and control populations regarding satisfaction, physical health, or medical adherence
    • There were 45 readmissions in the control and 38 in the intervention group, and a similar proportion of beneficiaries experienced at least 1 30-day readmission

    Key takeaways/implications

    • CHWs helped patients achieve 50% of their action plan goals and most patients (80%) provided positive open-ended feedback about the intervention
    • Health systems may leverage the CHW workforce to improve post-hospital outcomes by addressing behavioral and socioeconomic drivers of disease
    • Importantly, patient engagement was improved across all cohorts
    • Because researchers observed a substantial reduction of rehospitalization among the subgroup of readmitted patients, the study raises questions about population management. Namely, should health systems strive to improve a variety of outcomes in a broader population of vulnerable patients or target a narrow population at high risk for a particular outcome (i.e., hospital readmission)?
    • The intervention offers health systems a scalable strategy because it used a standardized approach to create tailored action plans for achieving patients’ individualized goals. Because the intervention was patient-centered, other health systems may use the same CHW recruitment, training, and work practice protocols for a range of patients across diseases and settings
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