Healthcare and More, by and for the Community

When Terri Kirkpatrick, a community health worker, meets a new client, the first question she asks is, “how are you feeling today?”

The question isn’t just an icebreaker. It’s laying the foundation for the relationship Kirkpatrick hopes to build with her clients. She knows how vulnerable and anxious women coming into Strong Beginnings feel. She was once a client of the program for pregnant Black mothers with behavioral health needs.

“I can truly say that I was born to be community health worker,” Kirkpatrick says, adding that she has an experiential understanding of the disparities the program’s clients live with.

Kirkpatrick has been a Strong Beginnings community health worker for 23 years. The program, a partnership between Spectrum Health, a Michigan-based managed care organization, and nine community organizations, facilitates home visits by nurses, nutritionists and community health workers.

Like most community health workers, Kirkpatrick has a job that takes her outside the traditional boundaries of healthcare. She helps the women in the program with whatever needs they might have, including food and housing, job and career support. “Whatever their priority is, that’s what I focus on,” she says. “I’m here for them.”

Boom times

The community health worker model has been around, in one form or another, for 100 years, says Scott Tornek, chief strategy officer for the Penn Center for Community Health Workers at the Penn Medicine. “It’s not a new concept,” says Tornek. “It has gone through boom-and-bust cycles for decades.”

Now it is booming. It started after passage of the ACA in 2010 and the subsequent move toward risk-based contracts that create incentives to reduce the cost of care and prevent illness. According to the CDC, more than 23 states have or are considering community health worker programs.

Yet community health workers have not been fully embraced by the U.S. healthcare system. Even if they result in overall savings, the programs can be expensive to operate. Pilot projects may get off to a good start but then shut down when the funding runs out.

But many experts, physicians and healthcare executives see the community health workers as a way to deal with much-talked-about social determinants of health. The question, then, concerns how hospitals, health systems, payers and government health officials can make community health workers part of the everyday reality of American healthcare. “It’s a complicated question,” Tornek says. “But I think it starts with sustainable funding, especially for Medicaid and for people who are underserved — marginalized people who are in those insurance groups.”

Penn’s program

About a decade ago, Shreya Kangovi, M.D., M.S., a pediatrician caring for patients in West Philadelphia, asked herself that same question. In the ensuing years, Kangovi, along with a team of researchers from the Perelman School of Medicine at the University of Pennsylvania, created the Individualized Management for Patient-Centered Targets, or IMPaCT, program. Some key aspects of IMPaCT were developed based on interviews with more than 1,500 patients. Each was asked what was stopping them from staying healthy. The answers: food, housing, transportation and other problems. Next, an operational program was designed. Kangovi and her colleagues tested IMPaCT in randomized controlled trials and published the results.

Tornek says the key to the program’s success is hiring the right people. “We look for people who reflect the patients we serve, who are from the same communities, who have shared life experiences, who are naturally empathetic, who are good listeners, and who will bring food to a neighbor in need who is sick,” Tornek says. “You can’t train for that.”

The IMPaCT program involves training community health worker managers, most of whom have a background in social work. The program integrates community health workers with the patient’s care team. Patient satisfaction with IMPaCT is high, Tornek says, and employee turnover is a low 2%.

Community health worker salaries can vary. In large cities, starting salaries range from the high-$20,000s to the mid-$30,000s. An experienced community health worker can make up to $52,000 a year, according to the website Explorehealthcarecareers.org.

“The community health worker quarterbacks the nonclinical and nonmedical relationship with the patient,” Tornek says. “The community health worker in our model helps patients set and achieve their goals to get back on track quickly. How does that translate into health? It could be controlling their diabetes by shopping for healthier foods so they stay out of the hospital.”

Three controlled, randomized studies showed positive results. But a study showing that community health workers could save money had not been done. That changed in February 2020, when Kangovi, now the executive director of the Penn Center, reported results in Health Affairs. The study followed 302 patients considered at high risk for health problems between July 2013 and October 2014.

The patients were randomly divided: 150 in an intervention group that received services from the community health workers and 152 in a control group. All patients came from “high-poverty neighborhoods” and each had at least two chronic diseases. At the study’s one-year follow-up, 98 patients in the control group had been hospitalized, compared with 68 patients in the intervention group. The total inpatient and outpatient bill for intervention patients was about $ 2.5 million compared with $3.9 million for the control group. Kangovi and her co-investigators reported that the team of community health workers saved Medicaid $1.4 million. They calculated that the savings divided by program expenses ($567,950.82) yielded a return on investment within a single fiscal year of $2.47 for every dollar invested.

Over the past seven years, IMPaCT and Penn Center’s 30 community health workers have seen 13,000 patients. Depending on the goals they are trying to achieve, most patients work with program’s community health workers for three to six months. Some return, but most don’t.

Penn has exported its IMPaCT program to 20 states and 50 healthcare organizations, large health systems, payers, nonprofit organizations and departments of health. The adopters include ChristianaCare in Delaware, BJC HealthCare in St. Louis and Blue Cross Blue Shield of North Carolina.

But even successful programs like Penn Center and Strong Beginnings are constantly concerned about funding. Strong Beginnings runs on an annual budget of $2 million and includes funding from federal and state sources plus a $500,000 contribution from Spectrum Health. Penn Center does not publish its annual budget, but Tornek says the organization’s external work is self-funded and that Penn Medicine pays for the patients it refers. “We are doing a lot with pretty limited resources, quite frankly,” Tornek says.

Community health worker programs need to be on a firm financial footing to help vulnerable patients and reduce admissions, Tornek says. He would like to see Congress and the federal government’s various health agencies increase funding and help build a sustainable, long-term infrastructure to support community health programs.

“It’s a compressed question,” Tornek says. “There is institutional racism and health equity issues. How do we level the playing field? It’s a complicated question, but I think it starts with sustainable funding.”

Robert Calandra is an independent journalist in the Philadelphia area who writes about healthcare and other issues. Aine Cryts contributed reporting.