Impact Of Community Health Workers Research Articles

490 Evaluating the Impact of Community Health Workers on Transplant Waitlisting for Socially Disadvantaged Patients – A Dialysis Organization’s Health Equity Pilot

490 Evaluating the Impact of Community Health Workers on Transplant Waitlisting for Socially Disadvantaged Patients – A Dialysis Organization’s Health Equity Pilot

Impact of community health workers on diabetes management in an urban United States Community with high diabetes burden through the COVID pandemic

ObjectiveCommunity Health Worker (CHW) interventions are promising approaches to increasing access to health care, garnering better health outcomes, and decreasing health inequities for historically marginalized populations. This study examines the impact of a health system-based CHW program embedded in the Diabetes Impact Project – Indianapolis Neighborhoods (DIP-IN), a large, place-based, multi-year intervention to reduce diabetes burden. We assessed the CHW program’s effectiveness in managing glucose control and reducing diabetes-associated complications across the COVID timeline. MethodsWe examined the association between the CHW intervention and diabetes management in 454 CHW patients and 1,020 propensity score-matched comparison patients. Using electronic medical records for encounters between January 1, 2017, and March 31, 2022, we estimated the CHW program effect using a difference-in-difference approach through generalized linear mixed models. ResultsParticipation was associated with a significant reduction (-0.54-unit (95 % CI: −0.73, −0.35) in glycosylated hemoglobin (A1C) on average over time that was beyond the change observed among comparison patients, higher odds of having ≥ 2 A1C measures in a year (OR = 2.32, 95 % CI: 1.79, 3.00), lower odds of ED visits (OR: 0.88; 95 % CI: 0.73, 1.05), and lower odds of hospital admission (OR: 0.81; 95 % CI: 0.60,1.09). When analyses were restricted to a pre-pandemic timeframe, the pattern of results were similar. ConclusionThis program was effective in improving diabetes management among patients living in diabetes-burdened communities, and the effects were persistent throughout the pandemic timeline. CHW programs offer crucial reinforcement for diabetes management during periods when routine healthcare access is constrained.

Impact of community health workers on quality of life in adolescents and young adults with sickle cell disease: The SHIP-HU study.

Health-related quality of life (HRQoL) is an important outcome for patients with sickle cell disease (SCD). It is often poor compared with other chronic medical conditions or measured as a multidomain disease-specific construct. We previously reported outcomes in the Start Healing in Patients with Hydroxyurea (SHIP-HU) randomized controlled trial in adolescents and adults with SCD at six clinical sites. Besides the primary outcomes, we also measured HRQoL as a secondary outcome. Patients in the intervention arm were each assigned community health workers (CHWs) who provided case management services. CHW services were independent of medical management, and medical managers were blinded to the study arm. Patients in the control arm received only standard of care. We hypothesized that having a CHW would improve HRQoL in patients enrolled in SHIP-HU. We did not find significant differences between domains of HRQoL in the two study arms. Possible explanations include selection bias of enrolled versus unenrolled patients, selection bias of sites, medical providers and medical management, enforced blinding, and a lack of cooperation between medical managers and CHWs. The importance of CHWs and HRQoL is nonetheless recognized based on the literature. Future interventions on HRQoL in SCD should consider alternative study designs and multimodal interventions.

Impact of community health workers on improving identification and primary care of hypertension among the urban poor – findings from Chhattisgarh state of India

BackgroundHypertension is a major health problem globally and in India. Around 60% of people with hypertension in India are not aware that they have the condition. Less than 30% of individuals with hypertension are on treatment. Existing studies have indicated that community health workers (CHWs) can play a useful role in expanding the care for hypertension. Evaluations are needed to study the impact when an intervention is implemented by the government in its existing large-scale CHW programme to improve the identification, regular follow-up and medication adherence for hypertension.MethodsChhattisgarh state implemented a pilot intervention to improve screening and follow-up for hypertension by equipping Mitanin-CHWs to measure blood pressure (BP). The study design involved an intervention-group and a comparison-group of urban slum population. The survey covered 5974 individuals (30–79 years age) in intervention-group and 5131 in comparison-group. Multivariate analysis was conducted to find out the effect of intervention on the desired outcomes.ResultsIn intervention-group, 80.2% of the individuals (30–79 years age) had been screened for hypertension whereas the proportion was 37.9% in comparison-group. For 47.0% of individuals in intervention-group, Mitanin CHW was the provider who measured BP for the first time. Around 16.3% of individuals in intervention-group and 9.5% in comparison-group had been diagnosed with hypertension. Around 85.9% of hypertension cases in intervention-group and 77.0% in comparison-group were on treatment. BP had been measured in preceding 30 days for 81.8% of hypertension-cases in intervention-group and 64.3% in comparison-group. Around 70.3% of hypertension-cases in intervention-group and 55.1% in comparison-group had taken their complete medication for last seven days. Multivariate analysis showed that CHW intervention was associated significantly with improvements in all the desired outcomes.ConclusionEquipping the CHWs to measure BP was effective in increasing the screening and identification of hypertension, regular measurement of BP of individuals with hypertension and the adherence to medication. This shows the potential if the one-million strong work-force of Accredited-Social-Health-Activists (ASHA) CHWs in India gets equipped for this role. Governments need to provide a stronger policy push to get this materialised.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania.

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

EPH7 Racial Disparities in Colorectal Cancer Outcomes: How Community Health Workers Can Increase Screening Uptake in the US

Analyze and evaluate the impact of community health workers (CHW) in increasing colorectal cancer (CRC) screening for Black men. Secondly, to encourage private payers’ investment in robust screening programs that will reduce medium-to long-term costs, improve outcomes, and decrease racial disparities in CRC mortality.

Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review.

While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support).Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.

Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review.

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women's health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

Partnering faith leaders with community health workers increases utilization of antenatal care and facility delivery services in Ethiopia: A cluster randomized trial.

BackgroundEthiopia and other countries continue to experience high rates of maternal mortality and neonatal deaths. Interventions are needed to increase utilization of antenatal care (ANC) and facility delivery services to improve outcomes.MethodsA cluster-randomized trial was conducted in the Amhara Region of Ethiopia, with 6 communities randomly assigned to receive the intervention and 12 communities monitored as controls. Intervention teams provided outreach to pregnant women and their families. Registry data were used to measure utilization of services provided at health centers in intervention and control communities.The intervention consisted of trained pairs of community health workers and Ethiopian Orthodox priests who worked together to promote health messages around safe delivery. The pairs visited pregnant women and their families in their homes to provide counseling, discuss concerns, and answer questions about ANC and facility deliveries. Intervention impact was measured using facility-level data on monthly number of ANC visits and facility deliveries at the health centers that served the intervention and control communities. Intervention effect was measured using difference-in-difference analyses estimated by generalized estimating equation models.ResultsDuring the 12-month intervention period, intervention facilities (n = 6) recorded 14% more ANC1 visits (relative risk RR = 1.14; 95% confidence interval (CI) = 1.09-1.19; P < 0.001) and 26% more ANC4 visits (RR = 1.26; 95%CI = 1.18, 1.34; P < 0.001) compared to control health centers (n = 12). The intervention health centers experienced a 10% increase in facility deliveries over what would have been expected had the intervention not occurred (RR = 1.10; 95% CI = 1.05-1.16; P < 0.001).ConclusionsPromotion of safe delivery through home visits by community health workers paired with Ethiopian Orthodox priests increased utilization of ANC and facility delivery services. This approach could leverage the influential role of faith leaders and increase the impact of community health workers in Ethiopia.Trial registrationNCT04039932.

The impact of community health workers on antenatal and infant health in India: A cross-sectional study

BackgroundCommunity health workers (CHWs) are central to India's strategy for reaching the Sustainable Development Goals around maternal and child health. Despite India's significant investment in these programs, few studies have analyzed the effect of CHWs across India. ObjectiveThis study aims to analyze multiple types of CHWs and their impact on a broad range of antenatal and infant health outcomes across India. MethodsIn this population-based cross-sectional study, we analyzed data of women interviewed by the most recent 2015–2016 National Family Health Survey-4 (NFHS-4) in India. This study performed multiple variable regressions to examine the effect of receiving ANC during pregnancy from 1) any CHW and 2) by specific type of CHW - Accredited Social Health Activist (ASHA), Anganwadi Worker (AWW), and Community/Village Health Worker (defined in Table 1) on antenatal and infant health outcomes. ResultsOf 166,498 women, 14.2% received ANC from any CHW with specifically 5.9% receiving from ASHAs, 10.2% receiving from AWWs, and 0.5% receiving from Community/Village Health Workers. Women who received ANC from an ASHA had increased ANC utilization (OR 1.77; 95% CI 1.65, 1.91) as well as quality (IRR 1.06; 95% CI 1.05, 1.08), increased early initiation of breast feeding (OR 1.20; 95% CI 1.12, 1.29), and decreased one-year mortality (OR 0.75; 95% CI 0.63, 0.88). Women who received ANC from an AWW had increased ANC utilization (OR 2.24; 95% CI 2.12, 2.37) as well as quality (IRR 1.07, 95% CI 1.06, 1.08) and increased early initiation of breast feeding (OR 1.30; 95% CI 1.26, 1.40). ConclusionReceiving ANC from ASHAs and AWWs is associated with improved ANC utilization, ANC quality, early initiation of breastfeeding and the key outcome of reduced infant mortality.

A scoping review of the roles, training, and impact of community health workers in oral health.

To synthesize English or Spanish-language literature on community health workers' (CHWs') roles, training, and impact in oral health. A scoping review conducted in accordance with the Arksey and O'Malley (2005) methodological framework. Electronic literature searches were conducted in Medline (Ovid), Embase (Ovid), DOSS, CINAHL, Web of Science, and Global Health CAB from inception of the databases to April 2020. Three reviewers independently conducted the title and abstract and full-text reviews. This was followed by data charting by three reviewers and data summarizing by two reviewers. Out of the 36 articles that met the inclusion criteria, most took place in the United States (n=15) with most published between 2012 and 2019 (12). CHWs were incorporated in programs that focused on access to dental care (n=10), oral health promotion only (9), early childhood caries (8), oral health promotion and services (5), and oral cancer screening (4). Common roles included providing oral health education and behavior change motivation to community members, facilitating utilization of dental services, and the delivery of diagnostic and dental services to community members. Training and outcomes were not consistently described across studies. CHWs have been used in oral health programs and interventions across a wide range of locations and contexts. The implementation and scaling-up of oral health CHW programs requires appropriate provision of training as well as community embedded monitoring and evaluation structures based on rigorous methods with clearly defined outcomes.

The Impact of Community Health Workers on HIV Therapy Outcome in Sub-Saharan Africa

In sub-Saharan Africa, the burden on HIV care givers is high. This resulted in renewed interest in community health worker (CHW) programs. We conducted a review of the literature to summarize CHWs' effects on HIV therapy outcome. We also investigated which CHW tasks might favorably impact treatment outcome.&lt;br/&gt; We conducted a comprehensive literature search in PubMed, Web of Science and Embase for papers published up to October 2018. The studies included were conducted on HIV-positive adults in sub-Saharan Africa and reported biological HIV outcomes. We systematically collected data on HIV therapy outcome and CHW tasks. We used Bayesian network modelling for the analysis of CHW tasks.&lt;br/&gt; We included 19 studies in total: 4 randomized controlled trials, 8 comparative cohort studies and 7 single arm interventions. In all studies, CHW interventions were beneficial or not inferior to standard of care (SOC). The more common tasks of CHWs involved an important human support component, with home visits being the most common task. Upon analysis we found indications that ART delivery, individual adherence support and frequent home visits were predictive of a successful CHW intervention, defined as improved therapy outcome compared to SOC or reaching 90% of treated patients being virally suppressed.&lt;br/&gt; We found that CHW interventions are not inferior to SOC and might even be beneficial. We hypothesize that ART delivery, individual adherence support and frequent home visits are predictive of a successful CHW intervention. Further research is needed to be able to judge whether any single task or a particular combination of tasks is significantly correlated with a successful CHW intervention, or whether such tasks are context specific.

Community health workers impact on maternal and child health outcomes in rural South Africa \u2013 a non-randomized two-group comparison study

BackgroundHome visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities.MethodsA non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth.ResultsHome visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3–0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9).ConclusionThe impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.

Protocol for LINKS (linking individual needs to community and clinical services): a prospective matched observational study of a community health worker community clinical linkage intervention on the U.S.-Mexico border

BackgroundLatinos are currently the largest and fastest growing racial/ethnic group in the United States and have the lowest rates nationally of regular sources of primary care. The changing demographics of Latino populations have significant implications for the future health of the nation, particularly with respect to chronic disease. Community-based agencies and clinics alike have a long history of engaging community health workers (CHWs) to provide a broad range of tangible and emotional support strategies for Latinos with chronic diseases. In this paper, we present the protocol for a community intervention designed to evaluate the impact of CHWs in a Community-Clinical Linkage model to address chronic disease through innovative utilization of electronic health records (EHRs) and application of mixed methodologies. Linking Individual Needs to Community and Clinical Services (LINKS) is a 3-year, prospective matched observational study designed to examine the feasibility and impact of CHW-led Community-Clinical Linkages in reducing chronic disease risk and promoting emotional well-being among Latinos living in three U.S.-Mexico border communities.MethodsThe primary aim of LINKS is to create Community-Clinical Linkages between three community health centers and their respective county health departments in southern Arizona. Our primary analysis is to examine the impact of the intervention 6 to 12-months post program entry. We will assess chronic disease risk factors documented in the EHRs of participants versus matched non-participants. By using a prospective matched observational study design with EHRs, we have access to numerous potential comparators to evaluate the intervention effects. Secondary analyses include modeling within-group changes of extended research-collected measures. This approach enhances the overall evaluation with rich data on physical and emotional well-being and health behaviors of study participants that EHR systems do not collect in routine clinical practice.DiscussionThe LINKS intervention has practical implications for the development of Community-Clinical Linkage models. The collaborative and participatory approach in LINKS illustrates an innovative evaluation framework utilizing EHRs and mixed methods research-generated data collection.Trial registrationThis study protocol was retrospectively registered, approved, and made available on Clinicaltrials.gov by NCT03787485 as of December 20, 2018.

Hispanic Secondary Stroke Prevention Initiative Design: Study Protocol and Rationale for a Randomized Controlled Trial.

BackgroundHispanic-Latino populations face a disproportionate stroke burden and are less likely to have sufficient control over stroke risk factors in comparison with other ethnic populations. A promising approach to improving chronic health outcomes has been the use of community health workers (CHWs).ObjectiveThe objective of this randomized controlled trial is to evaluate the effectiveness of a CHW intervention among Latino patients at risk of recurrent stroke.MethodsThe Hispanic Secondary Stroke Prevention Initiative (HiSSPI) is a randomized clinical trial of 300 Latino participants from South Florida who have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with health care navigation and social services through home visits and phone calls. The intervention also includes a mHealth component in which participants also receive daily text messages (short message service). The primary outcome is change in systolic blood pressure at 12 months. Other secondary outcomes include changes in low-density lipoprotein, glycated hemoglobin, and medication adherence.ResultsStudy enrollment began in 2015 and will be completed by the end of 2018. The first results are expected to be submitted for publication in 2020.ConclusionsHiSSPI is one of the first randomized controlled trials to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latino individuals who have had a stroke.Trial RegistrationClinicalTrials.gov NCT02251834; https://clinicaltrials.gov/ct2/show/NCT02251834 (Archived by WebCite at http://www.webcitation.org/72DgMqftq)International Registered Report Identifier (IRRID)RR1-10.2196/11083

The role and impact of community health workers in childhood obesity interventions: a systematic review and meta-analysis.

Childhood obesity increases the risk for poor health during childhood, as well as for adult obesity and its associated comorbidities. Children from racial/ethnic minority groups or who live in poverty experience elevated rates of obesity. One potential method for reducing childhood obesity disparities is to involve community health workers (frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served). The purpose of this systematic review and meta-analysis was to explore the role and effectiveness of community health workers in childhood obesity interventions. Eleven studies met inclusion criteria, of which nine were eligible for inclusion in the meta-analysis. Results demonstrated that community health workers played various roles in childhood obesity interventions in the home, clinic, school, and community setting. Interventions focused primarily on children from underserved populations. Meta-analytic findings demonstrated a small but significant impact on BMIz and BMI percentile (BMIz [7 studies]: -0.08, 95% CI: -0.15, -0.01, p=0.03, I2 =39.4%; BMI percentile [2 studies]: -0.25, 95% CI: -0.38, -0.11, p<0.01, I2 =0%). Findings from this review demonstrate that partnering with community health workers may be an important strategy for reducing childhood obesity disparities and advancing health equity.

Abstract 258: Impact of Community Health Workers in Management of Heart Failure: A Pilot Study

Background: Community health workers (CHW) are specially trained lay-people often used as liaisons between underserved communities and the health care system. Prior studies suggest that use of CHWs can improve patient outcomes and reduce costs in a variety of illnesses. The role of CHW in managing patients with heart failure however has not been studied. This pilot study assesses the effect of CHW on hospital readmissions and Emergency Department (ED) visits for heart failure patients in an urban setting. Methods: Patients admitted to the hospital with a primary diagnosis of acute decompensated heart failure between April 2016 and March 2017 were screened for a pilot program to receive weekly home visits by a CHW. Visits included standardized assessment of overall well-being, vital signs, weight management, symptom control, medication compliance, diet education, and healthcare appointment reminders. Abnormal findings were reported to a cardiology nurse practitioner who triaged complaints and made appropriate changes. For this pilot study, enrolled patients were matched using 31 variables with retrospective control patients admitted with heart failure who did not receive a CHW. Hospital admissions and ED visits were compared for the 6 months following the index admission vs. the 6 months prior. Results: Sixteen patients received weekly visits from a CHW for 6 months after hospital admission. These were matched with 16 control patients who did not receive a CHW. Patients who received a CHW experienced a 36% decrease in Emergency Department (ED) visits in the 6 months after enrollment compared with the 6 months before. Control patients, however, experienced a 40% increase in ED visits over the same period. Similarly, patients with a CHW experienced a 42% decrease in hospital readmissions while control patients experienced a 28% increase. There was no significant difference in mortality between the groups. Conclusions: This pilot study suggests that CHW may reduce healthcare utilization for patients with heart failure without negatively impacting mortality. Based on these findings, a larger study is warranted to assess the efficacy and cost-efficiency of CHWs in helping to manage patients with heart failure.

Impact of Community Health Workers on Elderly Patients’ Advance Care Planning and Health Care Utilization

Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review.

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending. We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design. Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all). Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

Practice and Power: Community Health Workers and the Promise of Moving Health Care Upstream.

Against the backdrop of historic upheavals in American health care, a resurgent interest in the role of community health workers (CHWs) presents important strategic and technical questions. The ability to successfully navigate these issues and expand the health care role and impact of CHWs will depend on how stakeholders reimagine elements of practice and structures of power in American medicine. Practice redesign and redefined power dynamics can help health care settings successfully integrate CHWs, address social determinants of health for patients and communities, and achieve the Triple Aim of improved outcomes, higher quality of care, and lower costs.