Project Summary

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project is expanding the use of a community health worker (CHW) program shown to improve quality of care and reduce hospital stays for patients facing socioeconomic disadvantage.

An estimated 34 million Americans live in poverty in the United States. People facing socioeconomic disadvantage are more likely to experience life challenges such as racism, job loss, social isolation, and lack of high-quality primary care. These challenges increase the risk of chronic health problems such as heart disease, diabetes, and obesity.

What is the goal of this implementation project?

CHWs are trustworthy people who come from the communities they serve. They can improve health within their communities through social support, advocacy, coaching, and navigation. A PCORI-funded study found that a standardized CHW program called IMPaCT improved quality of care and reduced hospital stays among patients living in low-income neighborhoods. In IMPaCT, CHWs get to know their patients’ life stories and provide tailored support based on patients’ needs and preferences.

This project will expand the use of IMPaCT to five healthcare organizations across the U.S. to support patients who live in low-income communities and have chronic health problems.

What will this project do?

The project team will adapt IMPaCT for the new sites, which include a federally qualified health center, three healthcare systems, and a health plan. Core parts of IMPaCT, such as guidance for hiring CHWs, will be the same for each site. The team will adapt other IMPaCT materials for local patients, caregivers, and clinicians by working with staff at each site.

The project team will support sites during the process of putting IMPaCT in place. The team will

  • Help recruit and hire CHWs who can build trust with patients
  • Train CHWs, people who directly supervise them, and people who oversee the CHW program at each site
  • Provide ongoing support and feedback
  • Refine the program as needed for each site

What is the expected impact of this project?

In this project, more than 4,000 patients who live in low-income communities and have chronic health problems will receive support from CHWs. The project evaluation will confirm whether IMPaCT is working as intended to reduce health disparities and hospital stays.

The project will show what’s required to extend IMPaCT to new healthcare sites. The sites have expressed a strong commitment to continuing and expanding the program after this project ends.

More about this implementation project:

Stakeholders Involved in This Project

  • Penn Center for Community Health Workers
  • Ballad Health
  • AltaMed
  • Kaiser Permanente
  • Christiana Care
  • NYC Health + Hospitals

Implementation Strategies

  • Adapt the program based on sites’ clinical needs and to work with sites’ existing resources and workflows.
  • Provide sites with tools to support implementation, including hiring algorithms, CHW documentation and reporting software, and follow-up online training assessments.
  • Train CHWs, supervisors, and directors, in-person and online.
  • Conduct cyclical small tests of change at sites.
  • Provide technical assistance to sites, including consultation.

Evaluation Outcomes

To document implementation:

  • Number of patients enrolled in CHW programs
  • Number of CHWs hired to deliver the program
  • Additional measures of acceptability, fidelity of program delivery, sustainability
  • Implementation barriers and facilitators

To assess healthcare and health outcomes:

  • Propensity score for all-cause hospitalizations

Project Information

Shreya Kangovi, MD, MS
University of Pennsylvania Perelman School of Medicine

Key Dates

February 2019
June 2023

Study Registration Information

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Collaborative Goal Setting with or without Community Health Worker Support for Patients with Multiple Chronic Conditions

Note: Aditi Vasan, MD, MSHP served as Interim Principal Investigator of this project while Principal Investigator Shreya Kangovi, MD, MS was on sabbatical in 2021.


Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
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Last updated: September 26, 2023