PCORI funds Dissemination and Implementation projects to increase awareness and promote the use of PCORI research findings to improve healthcare practices and health outcomes. This project is proposing to conduct dissemination and implementation activities for the results of the research project: Collaborative Goal Setting with or without Community Health Worker Support for Patients with Multiple Chronic Conditions.
1. What research finding is this project implementing?
In the 21st century, in the most developed country in the world, a black veteran living in poverty in southwest Philadelphia dies of diabetes at age 45. He is not unique. The burdens of most diseases are greatest among lower-income patients who often face social challenges (e.g., joblessness, isolation) that contribute to worse outcomes. Community health workers (CHWs) are trusted laypeople from the local community who can be hired and trained by healthcare organizations to support patients with social challenges. Though increasingly common, CHW interventions are often disease specific and difficult to scale across institutions, or they lack rigorous proof of effectiveness.
Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized CHW intervention that includes manuals, online tools, and software for CHW hiring, training, supervision, and clinical integration (http://chw.upenn.edu/). With support from PCORI, we conducted in Philadelphia, Pennsylvania, a multisite randomized trial of IMPaCT across a Veterans Affairs medical center (VAMC), a federally qualified health center, and an academic medical center. We randomly assigned low-income patients with multiple chronic conditions (n = 592) to usual care or the CHW intervention. Those assigned to a CHW developed individualized action plans for achieving their health goals and received six months of tailored social support including weekly contact. CHWs did activities with their patients that nurses, doctors, and social workers do not (e.g., exercised with patients at a local gym, reconnected patients with estranged family members, helped patients plant and tend to an urban garden).
At the end of the trial, we found that participants assigned to the CHW intervention had greater improvements in patient activation, had nearly double the odds of reporting high-quality primary care, and spent fewer total days in the hospital at six months and nine months. This reduction was driven by a shorter average length of stay and a lower mean number of hospitalizations among patients who were hospitalized. These results support two prior randomized controlled trials that have demonstrated IMPaCT’s effectiveness for improving quality of care while reducing hospitalization.
2. Why is this research finding(s) important?
Our original PCORI-funded trial was designed to answer the question, “As a patient with a chronic illness and limited resources, how can I address real-life challenges that make it hard for me to stay healthy?” The trial demonstrated that IMPaCT can improve outcomes that matter to both patients and healthcare delivery systems: fewer days in the hospital, improved patient-reported quality of care, and increased patient activation. If further implemented and scaled, IMPaCT could move the needle on improving health for millions of low-income Americans. In this proposal, we address the patient-centered question, “How can clinicians and healthcare systems implement and sustain effective, scalable CHW programs to help low-income patients stay healthy?”
3. What is the goal of this implementation project?
The objective of this project is to implement IMPaCT across three states and to reach a patient population of approximately 4,625. To do so, we will partner with the Wilmington VAMC, the Pittsburgh VAMC, and Blue Cross Blue Shield North Carolina’s (BCBSNC’s) new Medicaid program. After our team helps each of these organizations launch IMPaCT CHW programs, we will measure implementation and patient-level outcomes: (1) reach, or the number of people receiving support from an IMPaCT CHW; (2) staff fidelity to intervention manuals; (3) stage of implementation achieved, as measured by the Stages of Implementation (SIC) score, a validated theory-based measure that predicts variations in implementation behavior; and 4) all-cause hospitalizations for patients receiving IMPaCT versus matched control patients.
4. What is the project team doing?
The study team has developed an implementation bundle for adapting and implementing IMPaCT in new settings. Specifically, trained personnel from the study team will engage stakeholders in partner organizations and adapt existing intervention materials (e.g. manuals, training, and software) based on contextual inquiry with local patients, caregivers, and clinicians. We will preserve core components: (i.e., hiring protocols, robust program infrastructure, adaptability across diseases, and protocols for clinical integration) while allowing for specific tailoring to promote accessibility and uptake in new settings. The team will then support partner organizations in implementing a CHW program through hands-on support with hiring, training, data systems, program launch, ongoing rapid-cycle redesign, and evaluation. We expect to have programs up and running within 12 to 18 months of the proposed project period. After this point, programs will be able to enroll patients at a steady rate. With input from partner organizations, we have set goals for the reach of each CHW program appropriate to the scale of its eligible patient population: the Wilmington VAMC program will serve 500 patients per year, the Pittsburgh VAMC will serve 1,000 patients per year, and the BCBSNC program will serve 3,125 patients per year.
5. How is the team evaluating its implementation activities?
Numbers of patients enrolled in CHW programs will be extracted quarterly from partner organizations’ electronic medical records/claims system. Staff fidelity to intervention manuals will be assessed in three ways: staff role plays with standardized patients, online training and assessment modules, and direct observation. Stage of implementation completion will be tracked using the SIC tool, a validated, theory-based measure that tracks phases of implementation, including engagement, readiness planning, fidelity monitoring, and competency. All-cause hospitalizations will be tracked using administrative data from the national VHA Corporate Data Warehouse and Blue Cross Blue Shield claims data across the state of North Carolina. We will use propensity score weighted regression analysis to compare hospitalizations between enrolled and nonenrolled patients.
6. How is the team involving patients and others in this implementation project?
We will conduct in-depth qualitative interviews with patients, caregivers, and clinicians; we will use the data to adapt IMPaCT intervention materials according to local needs and preferences. The study team will engage with stakeholders from the partner organizations (e.g. clinicians, patient representatives, and health system leaders) at all stages of CHW program planning and implementation.
7. How will this project help ensure future uptake and use of PCORI results?
Leaders of partner organizations are committed to paying for operational costs of their CHW programs during and beyond the grant period. Our partner organizations are also well positioned to bring PCORI-funded research results into wider use. Veterans have high rates of chronic illnesses (72% compared with 40% of other US adults) and face up to a 14-fold higher risk of sociobehavioral issues. As such, the US Veterans Health Administration is interested in adopting IMPaCT and will be influenced by the proposed work. Medicaid managed care organizations present a similar opportunity for widespread scale. Nationally, Blue Cross Blue Shield companies provide health insurance for 6.6 million Medicaid beneficiaries in 19 states. While these companies are distinct, they view each other as peer organizations and have diffused prior innovations across their network. Thus, the proposed implementation project with BCBSNC has large potential for scalability to Medicaid populations through Blue Cross Blue Shield and other Medicaid managed care organizations.
Learn more about PCORI’s Dissemination and Implementation program here.
Related PCORI-funded Research Project
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.