Results Summary
What was the research about?
Ongoing health problems, such as diabetes or high blood pressure, are on the rise in the United States. Setting goals and breaking them down into smaller steps may help patients manage these ongoing health problems.
In this study, the research team wanted to learn if goal setting with support from a community health worker, or CHW, helped patients work on their goals and improve their health. CHWs are people from the community trained to help others with their health needs. All patients in the study set goals with their doctors. The team compared patients who had CHW support for meeting these goals with those who didn’t have such support.
What were the results?
After nine months, patients with and without CHW support didn’t differ in how they rated their physical health. Patients in both groups had higher ratings of physical health at the end of the study.
Compared with patients who didn’t have CHW support, those who did reported higher quality of health care. Patients with CHW support were also less likely to have more than one hospital stay during the study or return to the hospital in the same month if they did have a hospital stay.
After nine months, patients with and without CHW support didn’t differ in
- Management of ongoing health problems
- Mental health
- Confidence to manage their health
- Time spent in the hospital, if they had a hospital stay
Who was in the study?
The study included 592 patients living in neighborhoods with limited resources in Philadelphia. Of these, 94 percent were African American, and 2 percent were Hispanic. The average age was 53, and 62 percent were women. Patients had public insurance or no insurance. All had two or more ongoing health problems or one ongoing health problem and smoked. Patients received care from an academic clinic, a Veterans Affairs medical center, or a clinic that serves people with limited resources.
What did the research team do?
The research team assigned patients by chance to one of two groups: goal setting with CHW support or goal setting without support. Patients in both groups reviewed a handout describing behaviors that could help them manage their health problems. Then patients chose one health problem and set a long-term goal with their doctors.
After setting the goal, patients in the group receiving support met with a CHW. The CHW helped them set short-term goals, create a plan to help reach their goals, and connect to a weekly support group with other patients. CHWs talked with patients weekly for six months in their homes, communities, clinics, or by phone. CHWs also provided emotional support and feedback on patients’ progress. Patients in the second group kept working on their goals without CHW support.
Patients in both groups took a survey at the start of the study and again six and nine months later.
Patients, caregivers, and healthcare professionals helped design the study and adapt the goal-setting program.
What were the limits of the study?
The study took place in one city. Results may differ for patients living in other areas. The research team didn’t have information for veterans who had hospital stays outside of the Department of Veterans Affairs network.
Future research could test the CHW program in other places or for a longer time.
How can people use the results?
Health clinics can use the results of this study when considering ways to help patients manage ongoing health problems.
Professional Abstract
Objective
To compare the effectiveness of goal setting with or without support from community health workers (CHWs) for patients with multiple chronic conditions living in neighborhoods with limited resources
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 592 patients with multiple chronic conditions living in neighborhoods with limited resources |
| Interventions/ Comparators |
|
| Outcomes | Primary: self-rated physical health Secondary: chronic disease control, self-rated mental health, quality of primary care, patient activation, and hospital admission rates |
| Timeframe | 9-month follow-up for primary outcome |
This randomized controlled trial tested the effectiveness of a goal-setting program that included CHW support, called Individualized Management for Patient-Centered Targets (IMPaCT), compared with goal setting without support for improving self-rated physical health for patients with multiple chronic conditions. CHWs are trained community members who provide health coaching to patients and caregivers.
Researchers randomized patients to receive the IMPaCT program or no program. In both groups, researchers showed patients a low-literacy visual aid describing health behaviors that could help them manage chronic conditions such as hypertension or diabetes. Patients then chose a long-term health goal with their providers.
After setting the long-term goal, patients in the IMPaCT program met with a CHW to set short-term goals and create action plans. The CHW connected patients with a weekly support group and talked with patients weekly for six months in their homes, communities, clinics, or by phone. During these conversations, CHWs helped patients navigate the health system, offered coaching about goal setting, and gave patients feedback on their progress. Patients who were not in the program continued to work on their goals without CHW support.
The study included 592 patients living in neighborhoods with limited resources in Philadelphia. Of these, 94% were African American, and 2% were Hispanic. The average age was 53, and 62% were female. Patients had public insurance or no insurance and at least two of the following chronic conditions: hypertension, diabetes, obesity, or tobacco dependence. All received care at an academic practice, a federally qualified health center, or a Veterans Affairs medical center.
Patients completed a survey to assess study outcomes at baseline and again six and nine months later.
Patients, caregivers, and clinicians helped design the study, adapt the intervention, and select outcomes.
Results
After nine months, patients in the two groups did not differ in self-rated physical health; both groups rated their physical health higher at the end of the study than at baseline.
Compared with patients who were not in the program, those in the IMPaCT program
- Reported a higher quality of primary care (p<0.001)
- Were less likely to have multiple hospital admissions during the study (p<0.05) and readmissions within 30 days of an initial hospitalization (p<0.05)
The two groups did not differ in chronic disease control, mental health, patient activation, or length of hospital stay.
Limitations
The study took place in Philadelphia; findings may differ in other regions. For patients who received care at a Veterans Affairs medical center, analysis of hospitalization and readmission rates included data only from the Department of Veterans Affairs network and no other clinical settings.
Conclusions and Relevance
Compared with patients who were not in the program, those in the IMPaCT program showed no improvement in self-reported physical health but rated their quality of primary care higher and had fewer hospital readmissions.
Future Research Needs
Future research could test the IMPaCT program in different geographic regions or assess the long-term effects of using CHWs to achieve health goals.
Final Research Report
View this project's final research report.
Implementation
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Results of This Project
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Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- While the reviewers generally found the study design and report strong, they asked that the researchers present some methods more clearly and correct some of the reporting of results. The researchers changed how they reported significant results (now, Pvalues < 0.05) and used softer, pared-down language in reporting outcomes.
- Reviewers asked for clarification of the intervention, called Individualized Management for Patient-Centered Targets (IMPaCT), and asked for more information about how this method differed from existing models for using community health workers (CHW). The researchers added more information in the background section and explained how IMPaCT differs from other programs that use CHW.
- Reviewers questioned whether the primary outcome measure could truly assess the primary outcomes identified by patients, which were to feel better and not to be limited by my health. The researchers noted that they selected the measure with community partner input and that it includes specific questions about how the patient’s health might limit their activities. They added this information to the measure’s description.
- Reviewers said they need convincing that the intervention can scale to a larger population. The researchers added a paragraph to the conclusion section to discuss scalability and softened the language they used in making assertions about the program.