A Multi-center Trial of IMPaCT CHW Support for Chronically-ill Patients
A Multi-center Trial of IMPaCT CHW Support for Chronically-ill Patients
This is a multi-center randomized controlled trial comparing the effectiveness of community
 health worker (CHW) vs. usual clinician support in helping chronically-ill patients with low
 socioeconomic status to improve their health outcomes.
Community Health Workers (CHWs) have the potential to improve chronic disease outcomes among
 patients with low socioeconomic status (SES). Yet, widespread use of CHWs has been hampered
 by lack of standardized, scalable and evidence-based models. Our community-academic-health
 system team used participatory action research with low-SES patients to design IMPaCT
 (Individualized Management for Patient-Centered Targets). A randomized controlled trial (RCT)
 of 446 hospitalized patients with varied diseases demonstrated that a 2-week dose of IMPaCT
 improved access to care, mental health, activation, and quality of communication, while
 reducing recurrent hospital readmissions. We have adapted IMPaCT for use among low-SES
 primary care patients with multiple chronic conditions.

 This RCT is designed to evaluate the newly adapted IMPaCT model in 3 primary care settings -
 academic, federally qualified health center, and VA. Upon enrollment in the trial, patients
 will collaboratively set a chronic disease management goal with their primary care provider.
 Patients will then be randomized to collaborative goal-setting versus goal-setting augmented
 by 6 months of support from an IMPaCT CHW. Follow-up will be conducted at 6- and 9- months
 post-enrollment.

 The study design is a single-blinded, 2- armed, multi-site randomized controlled trial
 involving three clinic sites and 444 patients.
Inclusion Criteria:

 -  Patient of specific practice (Mutch/St.Leonards Court, Spectrum, PVAMC) for at least 1
 yr defined as having one office visit within preceding 12 months

 -  Resident of home ZIP code including ANY of the following 19104, 19131, 19139, 19142,
 19143, 19145, 19146, & 19151

 -  Has 2 or more of the following conditions: 1. Obesity: BMI30 2. HTN: ICD9 relating to
 HTN from EMR problem list or EMR ICD9 encounter diagnosis x2) 3.DM: ICD9 relating to
 DM from EMR problem list or EMR ICD9 encounter diagnosis x2) 4. tobacco (from EPIC
 Social History/Vital Signs)

 -  Has at least one poorly controlled condition based on the most recent value prior to
 enrollment: Obesity (BMI>=35); HTN (SBP >= 160); DM (HgBA1c >=9); Tobacco Use (>0
 cigarettes)"

 -  Is uninsured, insured by Medicaid, or dually eligible for Medicare and Medicaid or VA
 Insurance

 -  Has a scheduled appointment at a study clinic in the future.

 -  Community Health Workers/CHWs/IMPaCT Partners involved in the care of patients of the
 three practices will be included in the qualitative portion of this study.

 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.

 -  Currently enrolled in another study focusing on chronic disease management.

 -  Currently has a CHW

 -  No one will be excluded on the basis of sex or race.