CHWs Address Community Needs and Demonstrate Patient-Centered Care

CHWs Address Community Needs and Demonstrate Patient-Centered Care

The Penn Center for Community Health Workers, based in the U.S. state of Pennsylvania, has a staff of 40 employees that are fully supported by the Penn Medicine Health System. The Center began as a collaboration between the Philadelphia community and Penn Medicine researchers. Most employees are CHWs and collectively  provide support to 1,500 vulnerable, high-risk patients in West and Southwest Philadelphia.

Using information from CHW-led in-depth patient interviews, the Center created the IMPaCT (Individualized Management towards Patient Centered Targets) model to address barriers to care. IMPaCT CHWs work with both patients and providers to set health goals and action plans for reaching them.

The Penn research team also identified historical limitations of CHW programs, that were systematically addressed in the IMPaCT model:

1.     To prevent high turnover, clear CHW hiring guidelines were developed

2.     To reduce the disjointed care that could arise from disease-specific interventions, patient-centered care is emphasized

3.     To ensure measurable results, the model is scientifically tested

4.     To promote cohesive patient care, the program is well integrated into a traditional healthcare system

5.     To improve CHW performance, specific work protocols were established

The model, tested in a randomized control trial of 446 patients, demonstrated higher quality hospital discharge communication, and fewer recurrent hospital readmissions. These and other results from ongoing randomized controlled trials were used in a business model that led to Penn Medicine’s creation of the Penn Center for CHWs in 2014.

The center also attempted to address the disconnect with physicians by partnering with the Perelman School of Medicine to create a medical student course called the IMPaCT teaching service. In the course, students shadow CHWs for four weeks in order to understand the various life issues affecting the patients they treat.  Along the way students learn a few CHW skills, from connecting patients to social services to motivational interviewing to deep listening.

Find the full blog on

1. Kangovi S, Grande D,Trinh-Shevrin C. From Rhetoric to Reality-Community Health Workers in Post-Reform U.S. Health Care. New England Journal of Medicine) 06/2015; 372(24):2277-9. DOI: 10.1056/NEJMp1502569

2. Kangovi S, Mitra N, Grande D, et al. Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):535-543. doi:10.1001/jamainternmed.2013.14327.

3. IMPaCT (Individualized Management for Patient-Centered Targets) Manuals,

Donna Bjerregaard

Senior Technical Advisor, Initiatives Inc.

264 Beacon Street, Boston, MA 02116

Tel:  617 262 0293 / Fax: 617 262 2514 /


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