Knowles Molly, Vasan Aditi, Pan Ziwei, Long Judith A, Kangovi Shreya
Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, University of Pennsylvania.
Penn Center for Community Health Workers, University of Pennsylvania Health System.
Milbank Q. 2025 Jun;103(2):513-527. doi: 10.1111/1468-0009.70011. Epub 2025 Apr 16.
Policy Points Effectively implemented community health worker (CHW) programs improve patient health outcomes and quality of care, reduce health care costs, and are a key strategy for addressing social and structural drivers of health. As policymakers consider funding mechanisms for CHW programs, it is crucial to tie funding to evidence-based best practices while also allowing for innovation and context-specific adaptations.
Community health worker (CHW) programs represent a key strategy for addressing social and structural drivers of health and have the potential to improve patient health outcomes and enhance quality of care while reducing health care costs. However, challenges such as high staff turnover, lack of program infrastructure, and inadequate CHW support and supervision can hinder implementation and sustainment of effective CHW programs. Furthermore, few CHW programs have been successfully scaled across multiple organizations and communities. Individualized Management for Person-Centered Targets (IMPaCT) is an evidence-based CHW model designed to address these challenges by standardizing processes for CHW hiring, training, support, and supervision while still allowing for context-specific adaptation and tailoring. In this dissemination and implementation project, we evaluated implementation of IMPaCT across five geographically and structurally distinct sites serving diverse and varied patient populations.
Model fidelity was assessed across seven best practice domains via structured virtual observations with CHWs, supervisors, and program directors at each implementation site. Acute care use was evaluated using difference-in-differences regression modeling for patients enrolled in IMPaCT compared with a propensity score-matched control group. All implementation sites examined total hospital days per patient, and several sites chose to incorporate additional measures of acute care use such as the number of hospitalizations and emergency department visits.
We found that core program components were implemented consistently across sites, and three of five sites were able to both sustain implementation over a three-year period and demonstrate significant reductions in acute care use, consistent with previous randomized controlled trials of this program.
Health systems may be able to address social drivers of health and improve population health for patients who are low-income and patients of color by implementing evidence-based CHW programs with fidelity.
有效实施的社区卫生工作者（CHW）项目可改善患者健康结局和护理质量，降低医疗成本，是应对健康的社会和结构驱动因素的关键策略。在政策制定者考虑CHW项目的资金机制时，将资金与基于证据的最佳实践挂钩，同时允许创新和因地制宜的调整，这一点至关重要。
社区卫生工作者（CHW）项目是应对健康的社会和结构驱动因素的关键策略，有可能改善患者健康结局，提高护理质量，同时降低医疗成本。然而，诸如员工高流动率、缺乏项目基础设施以及对CHW的支持和监督不足等挑战，可能会阻碍有效CHW项目的实施和维持。此外，很少有CHW项目能在多个组织和社区成功推广。以患者为中心目标的个性化管理（IMPaCT）是一种基于证据的CHW模式，旨在通过标准化CHW招聘、培训、支持和监督流程来应对这些挑战，同时仍允许因地制宜的调整和定制。在这个传播和实施项目中，我们评估了IMPaCT在五个地理位置和结构不同、服务于不同患者群体的地点的实施情况。
通过对每个实施地点的CHW、主管和项目主任进行结构化虚拟观察，在七个最佳实践领域评估模型保真度。使用差异-in-差异回归模型对参加IMPaCT的患者与倾向得分匹配的对照组进行比较，评估急性护理的使用情况。所有实施地点都检查了每位患者的总住院天数，几个地点选择纳入急性护理使用的其他指标，如住院次数和急诊就诊次数。
我们发现核心项目组件在各地点得到了一致实施，五个地点中有三个能够在三年期间维持实施，并证明急性护理使用显著减少，这与该项目之前的随机对照试验结果一致。
卫生系统通过忠实地实施基于证据的CHW项目，可能能够应对健康的社会驱动因素，并改善低收入患者和有色人种患者的群体健康。
