Early Success of the Community Health Worker Pilot


CHW Photo-Maria Pinto Edit

Pictured are Community Health Worker Maria Pinto, and patient Ubaldo Goncalves

The Community Health Worker (CHW) Expansion Pilot Program, initially funded in December 2015, has continued to provide high-risk patients with accessible and integrated care services to better meet their needs. In conjunction with a nurse care manager, CHWs have worked to assist patients with a wide-range of services, including housing assistance, transportation, access to healthy foods, appointment reminders and coordination, social services, financial assistance, and general outreach and trust-building.

A look at preliminary data from the implementation of the CHW pilot model, focusing on a small number of patients who had worked with one of three CHWs for at least six months, showed notable successes in the following areas: improved access to primary care (a reduction in missed appointments, and an overall increase in primary care appointments scheduled), a reduction in high cost utilization (reduction in ED visits and hospitalizations), as well as improved health for patients suffering from chronic health conditions (improvements in diabetes and hypertension).

A more specific breakdown of data can be seen below:

  1. A decrease in DNK (missed appointment) rates from 34% to 18.9% (44% reduction)
  2. An overall increase in primary care visits collectively from 152 to 291 (91% increase)
  3. A decrease in hospitalizations and ED visits from 9 visits to 5 (44% reduction)
  4. For patients with a diagnosis of hypertension (n=8) there was an overall decrease in average systolic blood pressure by 9.4% (138 vs. 125). There was also a comparable 12.5% increase in the number of patients with blood pressure in control after the intervention.
  5. For patients with a diagnosis of diabetes (n=5), there was an 18.7% decrease in HbA1c (10.7% vs. 8.7%) and a subsequent 40% increase in the number of patients whose HbA1C was less than 9.0% (2/5 patients vs. 4/5).

    The expanded role of CHWs continues to give us the capacity to engage our highest-risk patients, who are medically complex and who struggle to manage their own health, with the services they need to improve health outcomes over time, while reducing any barriers to receiving regular care.