Back in May, we introduced the University of Pennsylvania Health System's high-value community health worker (CHW) program called IMPaCT. Given the questions many of you asked on how the program is structured and what the CHWs do day-to-day, we returned to Penn to shadow a CHW. One of our biggest lessons from that day is that without tools to effectively manage time and patients, CHWs can quickly burn out.
No two days are the same for a CHW. Creativity and effective listening are intrinsic to the role, which customizes support based on patients' needs. Each week, CHWs may perform home visits, attend clinical appointments, and work with patients in the community (e.g., at the gym to exercise, at the bank to open an account). Program leaders should build programs that allow for flexible daily activities to maximize patient impact. Cheryl Garfield, a lead CHW at Penn, shared three key strategies that enables herself and her peers to effectively care for their high-risk patients: an IT-based patient management platform, standardized patient assessments, and limited panel sizes.
1. Invest in an analytics platform to streamline patient information, provider contact data, and CHW performance management
Cheryl starts each day by logging onto IMPaCT's patient management platform, HOMEBASE. The IT-based system mines admissions data to identify patients eligible for programming (e.g., Medicaid beneficiaries or the uninsured who live in an identified hotspot ZIP code). She is responsible for reaching out to patients assigned to her using that algorithm. HOMEBASE allows Cheryl to quickly identify eligible patients who are a good match for the program. It indicates where the patient is currently being treated, the contact information of the patient's care team, and past involvement with the CHW program.
Throughout Cheryl's patient interactions, she uses HOMEBASE to track patient progress to their goals. CHW managers also use this information to measure CHW performance and offer additional support if necessary.
2. Establish scripted, standardized patient assessments to ease the intake process
Once Cheryl is equipped with her list of eligible patients to approach, she visits them to offer access to CHW services with a scripted overview. After a patient accepts services, Cheryl performs a standardized assessment to gather baseline information about the patient's clinical and psychosocial circumstances.
The assessment was carefully constructed to collect enough background data for CHWs to create a rapport with patients and develop a holistic understanding of their barriers and goals, but it does not require too many questions, which could overload patients. Each question is framed with nonjudgmental language to reduce patient stigma about revealing social needs.
3. Ensure small, yet active panel sizes to allow time for CHWs to offer intensive, community-based support
At Penn, CHWs have an average caseload of 15 to 30 patients. The size allows CHWs to build in travel time to meet the needs of patients in the home and the community. All patients live in a concentrated geography selected due to its poor health outcomes. CHWs report that the restricted area increases travel efficiencies and allows them to provide intensive, focused care.
This approach helps Cheryl make inroads with her patients during her relatively short timeline of support (two to four weeks). Pre-specified program durations help keep caseloads steady. CHWs aren't overloaded, but they do work with enough patients to achieve real program results: a 2:1 overall ROI.
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