Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities

Abstract

Question Is a standardized intervention delivered by community health workers effective for improving clinical outcomes across a Veterans Affairs medical center, a federally qualified health center, and an academic family practice clinic? Findings In this multicenter randomized clinical trial of 592 adults, self-rated health was similar among the intervention and control groups, but the patients in the intervention group were more likely to report high-quality primary care and a reduction in total hospital days. Meaning Interventions by a health system–based community health worker can improve patient-perceived quality of care while reducing hospitalization. Importance Addressing the social determinants of health has been difficult for health systems to operationalize. Objective To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, –3.1 days; 95% CI, –6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, –0.3; 95% CI, –0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, –0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, –0.17; P = .04). Conclusions and Relevance A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health. Trial Registration ClinicalTrials.gov identifier: NCT02347787 Identify all potential conflicts of interest that might be relevant to your comment. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Err on the side of full disclosure. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.