The Individualized Management for Patient-Centered Targets (IMPaCT)

Citation: Kangovi, S., Mitra, N., Grande, D., White, M., McCollum, S., Sellman, J., Shannon, R., & Long, J. (2014). Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial. JAMA Internal Medicine, 174(4), 535–543. https://doi.org/10.1001/jamainternmed.2013.14327

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Importance 

Socioeconomic and behavioral factors can negatively influence post-hospital 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 pre-specified primary outcome was completion of primary care follow-up within 14 days of discharge. Pre-specified 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 post-hospital 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 post-hospital outcomes by addressing behavioral and socioeconomic drivers of disease.