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Original Investigation |

Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes:  A Randomized Clinical Trial

Shreya Kangovi, MD, MS1,2,3,4; Nandita Mitra, PhD4,5; David Grande, MD, MPA1,4,6; Mary L. White2; Sharon McCollum2; Jeffrey Sellman, BA1; Richard P. Shannon, MD1; Judith A. Long, MD1,4,6,7
[+] Author Affiliations
1Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
2Penn Center for Community Health Workers, University of Pennsylvania, Philadelphia
3Spectrum Health Services, Inc, Philadelphia, Pennsylvania
4Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
5Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
6Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia
7Philadelphia Veterans Affairs Center for Health Equities Research and Promotion, Philadelphia, Pennsylvania
JAMA Intern Med. 2014;174(4):535-543. doi:10.1001/jamainternmed.2013.14327.
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Importance  Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors.

Objective  To determine whether a tailored community health worker (CHW) intervention would improve posthospital outcomes among low-SES patients.

Design, Setting, and Participants  A 2-armed, single-blind, randomized clinical trial was conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. Of 683 eligible general medical inpatients (ie, low-income, uninsured, or Medicaid) that we screened, 237 individuals (34.7%) declined to participate. The remaining 446 patients (65.3%) were enrolled and randomly assigned to study arms. Nearly equal percentages of control and intervention group patients completed the follow-up interview (86.6% vs 86.9%).

Interventions  During hospital admission, CHWs worked with patients to create individualized action plans for achieving patients’ stated goals for recovery. The CHWs provided support tailored to patient goals for a minimum of 2 weeks.

Main Outcomes and Measures  The prespecified primary outcome was completion of primary care follow-up within 14 days of discharge. Prespecified secondary outcomes were quality of discharge communication, self-rated health, satisfaction, patient activation, medication adherence, and 30-day readmission rates.

Results  Using intention-to-treat analysis, we found that intervention patients were more likely to obtain timely posthospital primary care (60.0% vs 47.9%; P = .02; adjusted odds ratio [OR], 1.52; 95% CI, 1.03-2.23), to report high-quality discharge communication (91.3% vs 78.7%; P = .002; adjusted OR, 2.94; 95% CI, 1.5-5.8), and to show greater improvements in mental health (6.7 vs 4.5; P = .02) and patient activation (3.4 vs 1.6; P = .05). There were no significant differences between groups in physical health, satisfaction with medical care, or medication adherence. Similar proportions of patients in both arms experienced at least one 30-day readmission; however, intervention patients were less likely to have multiple 30-day readmissions (2.3% vs 5.5%; P = .08; adjusted OR, 0.40; 95% CI, 0.14-1.06). Among the subgroup of 63 readmitted patients, recurrent readmission was reduced from 40.0% vs 15.2% (P = .03; adjusted OR, 0.27; 95% CI, 0.08-0.89).

Conclusions and Relevance  Patient-centered CHW intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population. Health systems may leverage the CHW workforce to improve posthospital outcomes by addressing behavioral and socioeconomic drivers of disease.

Trial Registration  clinicaltrials.gov Identifier: NCT01346462

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This figure outlines the Consolidated Standards for Reporting of Trials Diagram for this randomized clinical trial. IMPaCT indicates Individualized Management for Patient-Centered Targets.

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