By: Raina Kulkarni
Today the Penn Center for Community Health Workers (CHWs) has a staff of 40 employees that are fully supported by the Penn Medicine Health System. Most employees are CHWs and collectively they provide support to 1,500 vulnerable, high-risk patients in West and Southwest Philadelphia.
But five years ago the Center was just an idea. It began as a collaboration between the Philadelphia community and Penn Medicine researchers. Tamala Carter, one of the founding employees, said, “I almost didn’t apply for the job (of Community Based Interviewer), because it said ‘research’…I thought they would want me to have other technical skills, but they actually wanted my life experience and natural ability as a listener.”
Carter conducted over 100 in-depth interviews with low-income, chronically ill, or hospitalized West Philadelphia residents, asking for their ideas on improving healthcare. “It can be hard to understand – why isn’t their health on the forefront of their minds?” said Carter, “but they have life issues that they need to worry about instead.” Patients stated that traditional healthcare providers had a poor understanding of their life issues, from unstable housing to food and job insecurity. They wanted support from someone non-judgmental and with whom they could relate.
“It was research at this point, but we were also designing a program…we wanted to create something that gives people the tools to help themselves,” said Carter. The Individualized Management towards Patient Centered Targets (IMPaCT) model was created by carefully mapping the barriers that patients described into a design for interventions delivered by CHWs. Currently, IMPaCT community health workers collaborate with patients and providers to set health goals and action plans for reaching them. Next, they provide hands-on support to help patients achieve their goals, from exercising with patients at the local YMCA to coordinating transportation to a doctor’s appointment or providing emotional support during difficult times. Finally, CHWs connect patients to a source of long-term support, including primary care and a CHW-led support group, to ensure that patients stay engaged and motivated even after the intervention ends.
The research team also identified historical limitations of CHW programs and published a perspective highlighting them in the New England Journal of Medicine1 in 2015.
The five limitations were systematically addressed in IMPaCT:
- To prevent high turnover, clear CHW hiring guidelines were developed
- To reduce the disjointed care that could arise from disease-specific interventions, patient-centered care is emphasized
- To ensure measurable results, the model is scientifically tested
- To promote cohesive patient care, the program is well integrated into a traditional healthcare system
- To improve CHW performance, specific work protocols were established
The model was tested in a randomized control trial of 446 patients, where it was shown that patients who worked with CHWs for two weeks had better access to primary care, better mental health, reported higher patient activation, higher quality hospital discharge communication, and fewer recurrent hospital readmissions.2 These and other results from ongoing randomized controlled trials were used in a business model that led to Penn Medicine’s creation of the Penn Center for CHWs in 2014.
In its first year, the Center received a three-year, $1.5 million grant from the Patient Centered Outcomes Research Institute. This grant enabled the Center to expand from Penn Medicine facilities and conduct a multi-center randomized control trial at the Veterans Affairs Administration and a federally qualified health center in order to evaluate the effect of IMPaCT on chronic disease management. These studies have sparked interest in over 400 organizations across the United States who have downloaded the Center’s toolkit for implementing similar programs.3
Despite the successful creation and growth of the IMPaCT model, Carter’s work is far from done. She now interviews patients about their experiences working with CHWs in order to gauge the effectiveness of the program and inform work practices. She had overwhelmingly positive things to report, “So many patients are thankful for the support their CHW provided. It’s a simple thing, feeling like they have someone in their life that cares for them that’s different from a friend or family member…I spoke to a gentleman in his 80s, who took charge of his own health for the first time and actually quit smoking. He used to stay away from doctors out of mistrust and misunderstanding. He went to appointments initially because he didn’t want to disappoint his CHW, but then was able to educate himself.”
In another attempt to address this disconnect with physicians that patients have reported, the Center partnered with the Perelman School of Medicine to create a medical student course called the IMPaCT teaching service. In the course, students shadow CHWs for four weeks in order to understand the various life issues affecting the patients they treat. They also learn a few CHW skills, from connecting patients to social services to motivational interviewing to deep listening – skills that Tamala Carter has shown to be surprisingly powerful: “People are willing to share their deepest thoughts and feelings if you show them respect and that you care. If you sit down and really listen and don’t go in with ideas about what’s best, they will themselves tell you what’s best for them.”
Raina Kulkarni works for the Penn Center for Community Health Workers as a
research assistant and business administrator. She graduated from St. Louis
University in 2013, with a B.S. in Biology and minor in Economics and is a
current student at the LPS College, University of Pennsylvania. She is interested
in studying behavioral economics to improve healthcare outcomes.
1. Kangovi S, Grande D,Trinh-Shevrin C. From Rhetoric to Reality-Community Health Workers in Post-Reform U.S. Health Care. New England Journal of Medicine 06/2015; 372(24):2277-9. DOI: 10.1056/NEJMp1502569
2. Kangovi S, Mitra N, Grande D, et al. Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):535-543. doi:10.1001/jamainternmed.2013.14327.
3. IMPaCT (Individualized Management for Patient-Centered Targets) Manuals, http://chw.upenn.edu/toolkit.