Effectiveness of Patient-centered Community Health Worker Support to Help Patients Control Chronic Disease
Effectiveness of Patient-centered Community Health Worker Support to Help Patients Control Chronic Disease
The purpose of this proposal is to compare the effectiveness of community health worker (CHW)
 support vs. usual primary care for helping chronically-ill, low-SES patients to improve
 control of chronic conditions. Upon enrollment each patient will select one of their multiple
 chronic conditions as a focus for the trial and work with his/her PCP to set a chronic
 disease management goal. Patients are then randomized to receive usual primary care vs. CHW
 support for moving towards that goal.
Inclusion Criteria:

 -  Patient of target practices for at least 1 yr defined as having one office visit
 within preceding 12 month

 -  Home ZIP code including ANY of the following: 1. 19104 2. 19131 3. 19139 4. 19143 5.
 19146

 -  2 or more of the following conditions: 1. Obesity (BMI greater than 30), 2. HTN (ICD9
 relating to HTN in EMR), 3. DM (ICD9 relating to DM in EMR), 4. Asthma/COPD and
 tobacco dependence (ICD9 for asthma or COPD in EMR AND documentation of tobacco use)

 -  Uninsured, insured by Medicaid or dually eligible for Medicaid/Managed Medicare

 -  Patients who have scheduled appointments in the future.

 Exclusion Criteria:

 -  Will not provide informed consent for this study.

 -  Does not have the capacity to provide informed consent for this study.

 -  Previously enrolled in this study