Impact-with-certificateCharlotte Martin now takes twice as long to do her food shopping as before. “My ride doesn’t wait any more. He tells me to call when I’m in line!” But it’s not due to a physical disability. She’s reading nutrition labels on almost everything she puts in her cart, making sure nothing has a high-sodium content .. and that Irene Estrada, her community health worker, would approve. “Every time I look up, there’s Irene looking over my shoulder!” she said, jokingly.

While Estrada doesn’t really come on these shopping trips, what she has been teaching Martin has clearly made an impression. “I never paid attention till now,” Martin said. “I was on three medications for my blood pressure but since it’s dropped and stayed low, I’m on two… and I’m planning on getting down to one!

This turnaround in behavior resulted from Martin’s participation in Penn Medicine’s IMPaCT (Individualized Management for Patient-Centered Targets) program, which helps low-income patients with multiple chronic diseases stay out of the hospital. Partnering with specially trained community health workers, IMPaCT provides tools to help patients overcome the barriers to getting and staying healthy.

How Can We Help You Stay Healthy?

IMPaCT comprises two distinct models, both of which work with at-risk patients from five areas in West and Southwest Philadelphia identified as “hot spots” for chronic disease and high readmission rates. One focuses on the transition from hospital to home; the other, of which Martin is a part, works with outpatients.

Penn researchers relied on feedback from these patients to create IMPaCT. “We basically asked them, ‘What makes it hard for you to stay healthy?’,” said project manager Casey Chanton, MSW. Based on responses to several questions, they decided to use community health workers from the patients’ own communities, “people they can relate to,” Chanton said. “CHWs are ‘natural helpers’ in their own communities. They have good listening skills and are non-judgmental, patient and kind.”

The CHW helps patients navigate complex social services and health systems to reach their goals. They undergo one month of training to equip them with the necessary tools and skills to help patients. For example, they learn how to set patient-centered goals and motivate patients to change a health behavior. They also learn ways to help with the challenges of daily life, such as getting food, housing, child care and transportation. “If we don’t address these basic needs, how well can patients focus on their health needs?” Estrada said.

Safe Transitions from Hospital to Home

In the Transitions model, which was recently studied in a randomized trial, CHWs connect with hospitalized patients and continue to partner with them for two to three weeks after discharge. “They’re a bridge between inpatient care and their outpatient clinic and home care,” Chanton said.

A top priority, Chanton said, is finding a convenient primary care practice at the place of their choice and addressing barriers that make it hard to get there. For example, during the initial community interviews, “patients told us they use the ER because they lack childcare, money for clinic co-pays or don’t have transport to the outpatient clinic.”

Transitions CHW Cheryl Garfield sees her patients daily through hospitalization and then discharge, helping with barriers to health, such as stable housing, childcare, or access to food, and making sure they understand discharge instructions and can get their medications. Once patients returns home, she calls or visits a few times a week or more depending on their situation.

Garfield makes sure patients have a follow-up appointment with a primary care clinic and that they keep it. “I’ll call a couple days before to remind them!” She’ll also arrange transportation to the clinic, if necessary, and accompany them to the appointment, if the patient requests it. “I want to make sure I break down barriers so they can focus on their health.”

At the appointment, Garfield speaks with both the doctor and social worker about the goals the patient has set up and potential problems in attaining them. “IMPaCT gets them started on reaching their goals and then the patients work with their primary care doctors and social workers,” she said.

Both during and after the transition period, Garfield encourages her patients to call with questions or concerns. “I have patients I worked with last year who still call me just to say hi and let me know how well they’re doing,” she said. “It’s so good to know that they haven’t returned to the hospital.”

Reduced multiple readmissions was just one of the positive results from IMPaCT’s first randomized trial. The participants, all of whom live in low-income communities that account for a significant portion of readmissions to participating hospitals, also had improved engagement in medical care, patient experiences, and mental health. The model has now been integrated into routine practice on inpatient general medical teams at HUP and PPMC.

“We learned a lot from the trial but we continue to tweak the model,” said Shreya Kangovi, MD, MS, director of Penn Center for Community Health Workers. “Why is it working for one patient and not another? How can we make it better?”

Changing Health Behaviors

With the success of the transitions model, a new IMPaCT study started last summer, adapting the Impact-with-food intervention for chronic disease management in the primary-care setting. The IMPaCT Primary Care focuses on patients in the same high-risk neighborhoods.

Although participants in the study have multiple chronic conditions, tackling all can be overwhelming so patients work with their health-care provider to determine one achievable goal. “We ask patients what they want to focus on and then help them reach that goal,” Chanton said. “The program is very patient centered.”

A community health worker partners with the patient to break the goal down into achievable steps and then provides the necessary resources, for example, finding a free smoking cessation class if the patient’s goal is to quit smoking. To help motivate patients and keep them on track to meet their goals, the CHW might participate in an activity with the patient. Estrada has attended nutrition classes with her patients, gone on walks, and even worked out at the gym. “That’s the bonus. It helps me as well,” she said, smiling.

During the six-month, primary-care program, CHWs meet with each of their assigned patients at home at least three times in the first month and at least once in each of the other five months. Weekly calls keep tabs on the patient’s progress and more. “Sometimes patients just need us to listen, especially if they’re under a lot of stress,” Estrada said.

“When you know what you did worked, it feels really good," Estrada said. "Even before coming to this program, I liked helping people meet their goals. Now what I do makes a huge difference, with their health.”               

The IMPaCT model was specifically created to be universal and scalable for any group, disease or setting. “We started with a transition model and adapted it for chronic care,” Kangovi said. “Now we’re working with other departments at Penn and organizations across the country to adapt IMPaCT for their needs.”

Top photo: Charlotte Martin proudly displays the certificate she received for completing the IMPaCT Primary Care six-month program.  With her is community health worker Irene Estrada who helped Martin reach the goal of lowering her blood pressure.

Bottom photo: Irene reviews sodium content of food with Charolotte to make sure she's keeping her intake at a low level.

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