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April 17, 2018

Reproductions of this manual are not permitted without express written permission of:

Dr. Shreya Kangovi, Penn Center for Community Health Workers, 423 Guardian Drive, 13th Fl. Blockley Hall, Philadelphia, PA 19104

Cite as: Kangovi, S. Feldstein, J., Anabui, O. (2018). IMPaCT (Individualized Management for Patient-Centered Targets) Director Manual. http://chw.upenn.edu

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CONTENTSOverview Our Purpose Community Health Workers IMPaCT Model

IMPaCT Theory and Practice

IMPaCT Theory Standardized Structure Team Structure

Building a Community Health Worker ProgramEngage Stakeholders

Select Outcomes Identify the Right Patients for your CHW Program

Understand the Needs of your Patient PopulationSet Up Workflow and Reporting SystemCalculate Return on Investment

Building Your Team Recruit and Hire

Train and Certify Maintaining a High-Quality Community Health Worker Program Provide Organizational Leadership

Achieve Annual OutcomesKeep the Manuals FreshEnsure CHW Safety

Appendices

Notes

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OVERVIEWOUR PURPOSE

Healthcare organizations across the country face a daunting challenge: they need to reduce health care costs while providing high-quality care to the sickest, most vulnerable patients. For low-income individuals, their social determinants of health, or ‘upstream’ non-medical factors like housing instability, food insecurity and social isolation, underlie the challenges they face, which include:

Low-value healthcare utilization:1 Low-income patients are less likely than other patients to obtain primary and preventive care. They are more likely to visit the emergency room and require hospital admission (and readmission) for conditions that may have been preventable with primary care. This pattern is costly for the health system and harmful to patients.

Chronic disease management:2 Low-income communities often suffer from high rates of chronic diseases. Healthcare providers struggle to improve outcomes, for which they are increasingly held accountable. Yet, providers are unable to reach beyond the hospital and clinic walls to address the root causes of poor health such as homelessness and addiction.

Dissatisfaction and mistrust:3 Healthcare payment is increasingly influenced by quality scores measuring patient experience and satisfaction. Low-income patients report lower quality experiences of health care due to factors such as mistrust of institutional providers, and perceived discrimination based on race, insurance status, and class.

Capacity: Medicaid expansion has created an influx of new patients into the healthcare system, placing a potential strain on provider capacity. Clinical providers also spend a lot of their time performing non-clinical tasks, which worsens the strain. This under-supply of care (particularly primary care) can create major barriers to access for low-income patients, which in turn drives hospital use.

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Our purpose is to address these challenges through the effective use of community health workers.

COMMUNITY HEALTH WORKERS

WHO IS A COMMUNITY HEALTH WORKER?

Community Health Workers (CHWs) are trained laypeople who share life circumstances (race, education, language, etc.) with the patients they serve.4 Yet they are more than just demographic mirrors.5 The sociology literature describes CHWs as “natural helpers.”6 They are the kind of people who will bring soup to a sick neighbor or care for an aging parent.

CHWs work with patients in their homes and communities to address the underlying determinants of health. They do things that nurses, doctors, and social workers do not. They sit with patients on the front porch and talk about the struggles of daily life: the grief of losing children to violence; the embarrassment of not being able to pay bills; the confusion of coordinating complex medical care. CHWs provide both emotional and instrumental support—hands-on support that goes beyond just giving out information or referrals. For example, CHWs can go with patients to community centers and smoking cessation classes, read through insurance forms, or exercise together at the local gym.

WHO IS NOT NECESSARILY A CHW?

Navigators, health coaches, advocates, care coordinators, and case managers are terms that are often confused with CHWs. The difference is simple: these terms describe functions (things that people do), whereas a CHW is an identity. CHWs can perform the functions of navigator or coach, but so can nurses, student volunteers, or family members.

WHY ARE SPECIFIC QUALITIES OF A CHW IMPORTANT?

If anyone can perform the functions of a CHW, why choose a CHW? Can’t a nurse or college student just call or visit high-risk patients and support them in health behavior change?

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The social psychology and health disparities literature explain that the combination of shared life experiences and innate empathy gives CHWs the potential to be more effective than other personnel. The Penn Center for Community Health Workers conducted in-depth qualitative research with thousands of high-risk patients. These patients confirmed that they felt a sense of disconnect and often mistrust with traditional healthcare personnel who did not share their background. These patients wished for non-judgmental support from someone more relatable.

WHAT CAN CHWS DO?

CHWs have the potential to address many challenges that both healthcare organizations and vulnerable communities share. They can:

Navigate patients from the hospital setting to accessible preventive and primary care7

Reach beyond the clinic walls to address root causes of poorly controlled chronic disease8-10

Gain patients’ trust and improve their experiences of care Strengthen social capital and build capacity within communities Perform important non-clinical tasks better and more cost effectively

than expensive clinically-trained personnel

SOUND LIKE A MAGIC BULLET?

Changes in healthcare policy and financing over the past decade (from expanded access to health insurance to a growing emphasis on value-based purchasing and bundled payments) have led lots of healthcare organizations to consider using or start employing CHWs. To the average organization, CHWs may seem like a simple solution. However, more often than not, CHW programs have been, at best, ineffective, or at worst, resulted in adverse outcomes for patients.11 A historical perspective of the evolution of the CHW model in the United States is useful: 4, 12

The CHW workforce was formally established in the United States in the 1960s through federal legislation focusing on migrant and Native American populations (i.e. the Indian Health Service). The second phase (1973-1989), was characterized by disease-specific, grant funded projects. This phase moved the CHW model to populations beyond Native Americans and

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migrants but was limited because programs were disease-specific (e.g. diabetes promotoras), making them difficult to scale across populations and for patients with multiple comorbidities. Also, these programs came and went with grant funding. The third phase (1990-1998) saw an emphasis on CHW training and certification programs in an attempt to standardize and scale the model. This helped, but there was less emphasis on the important book-ends: recruitment and work practices. How should organizations recruit the right kind of people to train as CHWs? Training the wrong people is not likely to be effective. And, after CHWs are trained, what exactly should they do? The most recent phase (1998-2006) saw an increase in scientific evaluations of CHW programs, which was an important step. However, the Agency for Healthcare Research and Quality (AHRQ) rated much of this science as low quality.13

This brings us to the current era. As mentioned previously, changes in healthcare policy and financing have helped make the CHW workforce attractive to a whole new audience: health care organizations that are looking to improve outcomes among high-risk patients. To avoid the inconsistent (and sometimes adverse) results that CHW programs have yielded in the past, healthcare organizations need to invest in CHW programs that do five things:

1. HIRE THE RIGHT PEOPLE: Many organizations are unsure how to recruit and hire highly-qualified CHWs. Standardized CHW training will not work unless you have the right people in the room. This human resource

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uncertainty leads to high turnover14 and variable performance within the CHW workforce. Organizations need to use vetted hiring algorithms to identify, recruit and train high-quality CHWs.

2. BUILD ROBUST PROGRAM INFRASTRUCTURE: Organizations tend to over-emphasize CHW training, without defining what exactly CHWs should do after they are trained. On one extreme, this can lead CHWs to perform clinical duties for which they are insufficiently qualified, leading to adverse outcomes. On the other hand, CHWs may perform menial or overly prescriptive tasks (checklists, answering phones, etc.), leading to loss of productivity and job dissatisfaction. Further, many CHW programs focus only on the CHW without thinking about the many decisions that go into building program-level infrastructure: supervision, documentation, caseloads, safety protocols, etc. This can leave CHWs feeling unsupported and at risk for burnout or threats to their own personal safety.

3. HEALTHCARE INTEGRATION: CHW programs often come and go because they are linked to unsustainable grant or community funding. For the best, most sustainable outcomes, healthcare organizations need to integrate CHWs into their operations and finances, creating structures for CHWs to efficiently join existing care teams and financial models to demonstrate return on investment (ROI).

4. BE PATIENT-CENTERED, NOT DISEASE-CENTERED: Most evidence-based CHW programs are specific to a particular disease (e.g. diabetes) or role (e.g. navigation, coaching, etc.). But most patients do not just have one disease or one type of need. This narrowness can result in focusing on the wrong things for a particular patient and makes CHW programs difficult to scale across healthcare organizations. Successful CHW programs are patient-centered, focus on the whole person, and can be adapted to different diseases and settings.

5. RIGOROUSLY MEASURE OUTCOMES: The scientific evidence supporting CHW programs is often of low quality.13 Investing in a CHW model requires significant time, investment and risk. Yet, health systems often don’t think of requiring the same level of evidence they would to invest

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in a new drug or medical device. Organizations must select CHW models that have been supported by high-quality scientific evidence and that continue to rigorously collect, analyze and evaluate outcomes for continuous improvement.

THE IMPaCT MODEL

The Penn Center for Community Health Workers designed the IMPaCT model to address these five critical areas. The model, which we’ve refined and tested for nearly a decade, was designed based on hundreds of in-depth qualitative interviews,1, 15-17 and over 1,000 surveys18 conducted with high-risk patients. We used these studies to build the IMPaCT model, which includes protocols for several key areas:

RECRUITING AND HIRING CHWS:

Patients we spoke to wanted support from someone to whom they could relate: “I need to share with somebody that can share with me, like I’ve been there.” They suggested that CHWs should have a non-judgmental nature, the ability to “take time and listen,” to “work with people and have patience.” Patients emphasized the need for CHWs to “win their confidence and become part of their life. It’s not a fly by night thing. It has to be sincere from your heart that I’m going to be here for you no matter what you go through.”

IMPaCT has developed human resources guidelines and hiring algorithms, including behavioral questionnaires and case scenarios for job applicants, which help recruit and hire individuals who possess the qualities that high-risk patients seek.

TRAINING AND CERTIFICATION:

Patients explained that most issues that made it hard for them to stay healthy were not really medical issues and were not specific to any one condition like diabetes or hypertension. Instead, they were “real-life issues” that fell into the following categories: psychosocial, health system navigation, resources, neighborhood, and healthy behaviors.

IMPaCT has developed college-accredited training that teaches CHWs how to effectively work with patients in the healthcare setting, community and

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home. It teaches CHWs to address the issues (psychosocial, navigation, etc.) which patients described as health barriers and provides certification checkpoints to ensure new CHWs have mastered core elements of the job.

STANDARDIZED CHW CARE:

Patients wanted care that was tailored to their needs and goals. In the IMPaCT system, CHWs provide patient-centered care in three stages:

SET GOALS: IMPaCT CHWs work with patients and their providers to set a health goal that is important and achievable. Then, they help patients create tailored action plans, or Roadmaps, towards reaching their goal.

SUPPORT: CHWs provide hands-on support to help patients achieve their goals: coaching, supporting, and navigating to social and medical resources. Their tasks could include anything from helping patients make appointments, to understanding discharge summaries, and getting medications. But they also provide support by calling, texting, sitting on the porch, working out together at the local gym, going to the grocery store, or organizing a support group. CHWs are experts in using novel and non-traditional approaches for patient care and do whatever it takes to get patients to the finish line. The main types of support that CHWs provide are:

o Emotional support – actions to make patients feel cared for, such as listening to patients’ hopes and fears and validating their experiences and feelings

o Instrumental, or hands-on, support – doing something with or for patients, such as going to the grocery store together or dropping off a benefit application form to the local welfare office

o Informational support – actions to provide patients with information, such as how to cook low-salt recipes

o Appraisal support – actions to provide patients with accurate assessments of their current situation, such as motivational interviewing

CONNECT: The hardest part of any intensive support model is the end. Patients often lose ground after an intervention ends due to the voltage drop in support. IMPaCT CHWs work to transition patients to a soft

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landing. For recently hospitalized patients, this means getting them into a primary care practice that can meet their needs. IMPaCT CHWs can also transition patients to weekly support groups that they facilitate. These groups are a powerful way for patients to support each other and solidify the health gains they have made for the long-term.

This standardized care also includes program infrastructure in critical areas such as team structures, caseloads, duration, and HOMEBASETM an electronic, secure documentation and reporting system.

SUPERVISION AND INTEGRATION:

Community health workers don’t work in isolation. We have created manuals for:

• Directors: these are the people who want to take the lead in running a CHW program at their institution. This manual, which you are reading now, provides guidance on important topics like calculating return on investment, hiring and training, and maintaining quality.

• Managers: these are typically social workers who will be directly supervising CHWs. This manual provides guidance on topics like day-to-day supervision practices, on-going training, avoiding burnout, and integration with healthcare teams.

• Community Health Workers: these are the natural helpers you have hired to work directly with patients. These manuals, one for inpatient and one for outpatient CHWs, provide guidance on topics like daily work with patients, responding to patient emergencies, and how to stay safe in the field.

• Coordinators: these are the individuals who identify and, in some cases, enroll eligible patients in IMPaCT and who collect data to evaluate the program. The Penn Center for CHWs can help you customize the Coordinator manual for your local setting.

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HIGH-QUALITY RESEARCH AND EVIDENCE:

IMPaCT has been tested among high-risk patients in three randomized controlled trials. The model has been proven to:

Help with weight loss, diabetes control and smoking cessation Improve mental health Improve discharge communication and the quality of primary care Increase access to post-hospital primary care by 12% Lower hospitalization rates by 30%

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IMPaCT THEORY AND PRACTICE

IMPaCT THEORY

GOAL-SETTING:

IMPaCT is built on the science of goal-setting. Most people are better at reaching goals if they are broken down into baby steps or short-term goals, and if they have a clear path to follow. IMPaCT CHWs help patients work backwards from a long-term health goal and create a Roadmap for reaching that goal19.

Roadmaps are plans that use a patient’s resources to achieve short-term goals that patients feel confident about achieving. These short-term goals will eventually lead to the long-term health goal20.

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1. LONG-TERM GOAL: Patients start by choosing a long-term health goal that is clear and measurable. This is something that patients can do with the help of their health care provider. For instance: “I want to stay out of the hospital for the next 6 months” or “I want to get my blood pressure to 140/90.”

2. SHORT-TERM GOALS: CHWs then ask the patient what they think they will need to do to reach this long-term goal. These are the patient’s short-term goals.

3. ROADMAP: After helping the patient identify short-term goals, CHWs help patients create action plans, or Roadmaps, for each short-term goal. Roadmaps have five components. See the Roadmap chart on the next page.

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ROADMAP SECTION DESCRIPTION SPECIFIC EXAMPLE

SHORT-TERM GOAL STATEMENT

CHWs work with patients to create a specific, measurable goal, so that they will know when they have accomplished it.

“In order to lower my blood pressure, I need to learn how to cook a low-salt recipe.”

CONFIDENCE

IMPaCT CHWs ask the patient how confident they are that they’ll be able to reach that goal by using this picture:20

“How confident are you that you can cook a low-salt recipe?”

Patients score their confidence using a scale of 1-10. If patients score below 7, the CHW should go back and ask them to pick a slightly easier goal.

RESOURCES

The things, people, or ideas that the patient thinks might help them get to their goals.

“My sister and I like to cook together and she’s interested in low-salt recipes as well.”

CHW has a copy of a low-salt recipe book.

PLAN

The concrete next steps that need to get done to make sure the goal is reached. The Plan gets updated every time the CHW talks to the patient. CHWs make sure each plan has a ‘who, what, when, where.’

CHW to help patient find low-salt recipes by Monday.

CHW to cook low-salt meal with patient and his family by next Friday.

RESOLVED?Has the patient achieved their short term goal? CHWs make goals specific and measurable from the beginning, so they know when they’ve been achieved.

When patients can demonstrate that they have reached a goal, the Roadmap is resolved.

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THE INTEGRATED BEHAVIOR MODEL

Sometimes people have a hard time reaching their goals. The Integrated Behavioral Model21 (IBM) is a sort of checklist to think about why a patient may be struggling to change his/her behavior and to reach goals.

BELIEFS: Does the patient have beliefs about the short-term goal that are preventing progress? For example: “Eating is the best way to enjoy life.” Beliefs are hard to change, so CHWs might need to work around them: in this example, instead of encouraging the patient to diet, a CHW could go produce shopping with the patient as a way to enjoy healthy food.

ATTITUDES: How does the patient feel about the behavior? What do they think are the pros and cons? CHWs can try to find out using motivational interviewing. Sometimes just getting the patient to understand their attitudes towards a behavior helps to move them along.

OTHERS’ BEHAVIORS: Can you use social norms to encourage change? CHWs are a built-in social norm. They should be practicing good health behaviors with the patient (going for walks, eating healthy foods, etc.)

OTHERS’ EXPECTATIONS: Is there someone whose opinion this patient cares about? Can this person keep the patient accountable to their goal?

CONTROL/SELF-EFFICACY: If the person “just can’t” seem to stick to the plan and get to the short-term goal, try breaking it down into even smaller steps and getting things done. Small successes make patients feel more confident in taking the next step.

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EXTERNAL BARRIERS: Even when patients are very motivated to reach their goals, they often face external obstacles: lack of transportation, competing issues like homelessness, etc. CHWs can help address these external constraints so that patients can reach their health goals.

KNOWLEDGE: Does the patient know the information they need to reach the short-term goal? If you’re not sure, test them with a teach-back: for example, does the patient know how to give himself insulin? Have them show the nurse/pharmacist in the clinic or by using a CHW phone video recorder.

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PROFILES

Through our research, we have found that there are generally four types of patients, which we call Profiles A, B, C and D. During the Meet the Patient interview, CHWs get a sense of which profile fits their patient, and use this knowledge to tailor their support to patients over the course of the IMPaCT program.

Of course, not all patients fall neatly into one of these Profiles, but they provide a useful framework to help CHWs assess patients and tailor their support. See the Profile chart on the next 2 pages.

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PROFILE DESCRIPTION CHW SUPPORT FOCUS

PROFILE A

• Traumatic experiences (jail, sexual assault, murder, etc.)

• Social/family dysfunction• Mental illness• Substance abuse• Housing instability• Disabled• Already uses resources like

disability check, Parole Officer, case worker, etc.

• Comes to the hospital a lot (more than 5 times in 6 months)

• Not very motivated to work on Roadmaps

Emotional Support:• CHWs should listen to these

patients and get to know them. They should not force them to make short-term goals they are not ready to make.

• CHWs should focus on providing emotional support, helping them to find meaning in life, and connecting them to supportive people to help them when the IMPaCT program is over.

PROFILE B

• Supportive family• Caregiver burden: lots of

friends/family are also sick or have problems. The patient cares for them, often more than they care for themselves

• Job stress: patients have to get back to work which makes it hard to recover when they are sick

• Can’t afford medications or medical care

• Very motivated to work on Roadmaps but struggles to find time

Instrumental Support:• CHWs should connect these

patients with community resources, insurance, etc.

• CHWs should help them get things done and reach their short-term goals.

PROFILE C

• Medically complex, frail and often elderly

• Terminal condition like end-stage cancer

• Going back and forth to the hospital often for severe illnesses that are not just due to social issues

End of Life Support:• CHWs should talk to the

care team with the patient to understand their prognosis

• CHWs should help the patient to think about the end of life, and talk about it with their family or friends

• CHWs should connect the

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patient to support for the end of life, including home nursing or hospice.

PROFILE D

• Independent• Relatively healthy and may not

have a deeply rooted cause of their health problems

Inform and Empower: CHWs should respect that

this patient may not need or want much support. Provide whatever information or support they ask for, but otherwise back off!

Don’t talk down to these patients. Do the opposite: ask them to be a role model for other patients or share their strategies at group

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THE ARC

A CHW-patient relationship should ideally progress through four stages. This is how we explain the Arc to CHWs.

Listen. You should listen INTENTLY to the patient and also talk to caregivers and the medical team. Try and get a ‘Snapshot’: a sense of who is this person, what is important to them (hopes/fears) and what, if anything, is the root cause of their health problems.

Snapshot. As you listen, reflect and ask questions, you will develop your Snapshot. It may not always be crystal clear at first and can evolve with time. The Snapshot is something you develop with the patient, reflects both strengths and challenges, and continues to be refined over time. As you do the Meet the Patient Interview, and throughout your relationship, share your Snapshot out loud to see if the patient agrees: “Ms. Jones it seems to me that you are a strong, caring mama-bear. You’ve lost your son recently and that’s been so hard that you picked up smoking again. Now you’re looking for a quick, convenient stress release to replace cigarettes.”

Roadmaps. List the goals that you and your patient set for your time together. Prioritize the goals that make sense given their Snapshot and best address the root cause of their health troubles. Map out a Roadmap for each goal using the Roadmaps form.

Do it now! For each Roadmap, get as much done as you can right there in the moment. Make calls, look things up on the internet, get busy. Putting things off takes the wind out of everyone’s sails.

If CHWs follow these stages, they will have a better chance of spending their time wisely and doing work that really makes a difference for patients. If not, they may spin their wheels with busy work that doesn’t link back to the patient’s core needs.

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STANDARDIZED STRUCTURE

As mentioned previously, IMPaCT programs follow a standard basic structure:

SET GOALS: IMPaCT CHWs work with patients and their providers to set a health goal that is important and achievable. They then help patients to create tailored action plans towards reaching their goal.

SUPPORT: IMPaCT CHWs provide hands-on support towards helping patients achieve their goals.

CONNECT: IMPaCT CHWs work to connect patients to a source of long-term support in order to prevent the voltage drop that often occurs after an intensive program.

This core model has been adapted for inpatient and outpatient settings. The goal of the inpatient program is to help patients stay healthy after discharge. The goal of the outpatient program is to help patients achieve a health goal they set with their doctor. Each of these goals takes different lengths of time, which creates a recommended program duration. The duration in turn drives the average (at any given time) and annual caseloads. A summary of these details is included below. Additional details on the specifics of the inpatient

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and outpatient models can be found in the CHW manuals and Manager manuals.

Inpatient OutpatientGoal Stay healthy after

dischargeAchieve a health goal set

with providerDuration 3 months 6 monthsRunning caseload

18-20 25-30

Annual caseload

75 50-60

TEAM STRUCTURE

A single IMPaCT Team is composed of one Manager (typically an MSW), a half-time Coordinator, and up to eight CHWs. Because IMPaCT is not disease or setting-specific, CHWs can be spread across different practices or settings (e.g. A single Manager can supervise 4 inpatient CHWs providing support to hospitalized patients, 2 outpatient CHWs working in primary care practices, and 2 outpatient CHWs working in pediatric practices). As Director, you can provide high-level oversight for up to eight teams.

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Staffing ratios: One Director, assisted in the early-stages by a Community-based Interviewer (see: ‘Building a CHW Program’. This Director can oversee 8 teams. Each Team has one Manager, a Coordinator, and up to eight CHWs

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An important note: these staffing ratios apply to situations of steady state. In other words, if you are hiring brand new CHWs, they will require more supervision, so adjust accordingly. We recommend a ratio 1 Manager to 4 CHWs for new hires.

The core functions of each team member:

DIRECTOR:

Engage partners and secure support, including sustainable funding Lead strategic decision-making process: select outcomes, identify patient

population, determine where CHWs are allocated within healthcare organization, etc.

Develop and manage return on investment model, including cost savings and operational budget

Recruit, hire, train and certify IMPaCT CHWs and Managers Ensure high-quality outcomes Ensure CHW safety

MANAGER:

Help recruit, hire, train and certify CHWs Support CHWs in day-to-day work with patients Support CHWs in urgent situations (e.g. patient emergencies or safety-

related incidents) Integrate CHWs into care teams Provide team leadership Ensure high CHW performance • See the Manager manual for job details

COMMUNITY HEALTH WORKERS:

• Provide social support, navigation and advocacy to high-risk patients in order to help them reach their health goals

• See CHW Manuals for job details

COORDINATOR

Accept provider referrals

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Identify and enroll patients who meet eligibility criteria for your CHW program

Collect and analyze outcomes data The Penn Center for CHWs can work with you to adapt the Coordinator

manual to your local setting

As Director, you should be familiar with the IMPaCT manuals for all roles. These manuals are similar to your manual; they include context for doing the work, step-by-step guides for daily work flow, job expectations, and interview guides/documentation forms. Each manual has been written to the appropriate reading level for its end user.

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BUILDING A CHW PROGRAM There are six key steps you need to take when designing your CHW program. These are complicated decisions that require expertise. The Penn Center for CHWs is available to provide technical assistance to help you with these steps, which are summarized briefly here:

1. Engage stakeholders 2. Select outcomes 3. Identify the right patients for your CHW program 4. Understand the needs of your patient population5. Set up workflow and reporting system6. Calculate return on investment

ENGAGE STAKEHOLDERS

The strongest CHW programs are health care-community organization partnerships. You have the best chances of success if you engage these stakeholders prior to starting your CHW program.

A. COMMUNITY-BASED ORGANIZATIONS (CBOs)

You should tap into the expertise of CBOs that are located within and/or serve the population that you intend to help. Select organizations that have (a) a mission of serving high-risk, low-income patients, (b) a track record of success, and (c) a history of partnering with other institutions. For example, the organization we partnered with to design the IMPaCT model was a community health center located in the center of our high-risk geographic area that had served the community for 45 years. CBOs will help you to:

• Recruit qualified CHWs and Managers• Provide guidance to ensure that your program is grounded in community

needs• Help you build your database of community resources

B. HEALTH CARE ORGANIZATION LEADERSHIP

IMPaCT was designed to have a positive Return on Investment (ROI) for health systems (providers and/or payers). You can use our sample program

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budget to build support for a CHW program from your chief executive officer, financial officer, and medical officer. Health system leadership will approve sustainable funding for the model and connect you to:

• Data Analytics, who will help you access data that you need to select your target patient population and initial clinical sites

• Information Technology, who will help you access and integrate with health system infrastructure like the Electronic Medical Record

• Human Resources, who will help you coordinate hiring and onboarding new staff

Accessing these systems can take time, so be sure to start early.

SELECT OUTCOMES

IMPaCT is flexible and can improve outcomes for a variety of challenges shared by health care organizations and vulnerable communities, such as chronic disease control, primary care access, readmission, etc. (See: Our Purpose). A useful framework for selecting outcomes for your CHW program is The Institute for Healthcare Improvement’s Triple Aim of Healthcare:

Improve the health of populations Improve the patient experience of care (including quality, access and

satisfaction) Reduce the per capita cost of health care

Choose a few outcomes to start with so you can clearly define your scope and evaluate your success. We recommend selecting measures where there is an evidence base for success. The IMPaCT model has been proven to improve:

Healtha. Chronic disease controlb. Self-rated mental and physical health

Qualitya. Quality of care and communicationb. Access to primary carec. Likelihood to recommend program

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Costa. Hospital admissions and readmissionsb. Annual reach, or number of patients served by the program

Select outcomes that are valued by your patients and have financial implications for your partner healthcare organization. Working at this intersection of heart and dollar signs keeps your CHW program mission-driven and economically viable.

IDENTIFY THE RIGHT PATIENTS FOR YOUR CHW PROGRAM

There are many approaches to stratifying a population of patients into smaller groups who may benefit from a particular intervention, such as a CHW program. This is a vast topic and we do not intend to cover it comprehensively here. However, here are guidelines to keep in mind:

A. TARGET PATIENTS WHO ARE MOST LIKELY TO BENEFIT

Not every patient needs a CHW. Patients with high psychosocial risk, across a spectrum of medical risk, are most likely to benefit from the type of support a CHW provides. This means that a CHW program can fit within a more comprehensive range of services your organization provides:

High psycho-socioeconomic risk: CHW program High medical but low psycho-socioeconomic risk: home care

nursing/hospice Moderate risk: evidence-based telemedicine or connected health

interventions (e.g. automated appointment reminders, health apps, etc.)

Low-risk: triage these patients to clinical personnel like physician extenders.

B. SELECT SIMPLE CRITERIA AVAILABLE IN REAL TIME

CHW programs work best when CHWs start working with patients on the first day of their hospital admission or at a doctor’s appointment. So pick simple, EMR-extractable data that help you quickly and easily identify patients with high psychosocial risk, like insurance type (as a proxy for

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income) and zip codes with high concentrations of poor health outcomes (e.g. readmissions, high rates of chronic diseases).

C. DO NOT RELY SOLELY ON REFERRALS

While provider referrals are an important component of clinical integration, they should not be the sole source of patient selection. Providers tend to over-refer patients with frequent hospital admissions and mental health issues (in other words, Profile A patients), overlooking patients with less obvious difficulties (ex: caregiver burden) who may have significant needs and would benefit from a CHW.

D. SELECT A CONTIGUOUS GEOGRAPHY

CHWs do most of their work in patients’ home and communities. Use the data provided by your organization’s data analytics team and techniques such as geocoding to target neighborhoods with the highest concentration of patients who will benefit from your program (e.g. concentrations of high psychosocial risk). In addition to creating travel efficiencies for CHWs, a geographic concentration allows you to build relationships with resource agencies (where you will refer patients) and CBOs (who will help identify prospective CHWs and provide guidance to make sure your program is grounded in community needs).

UNDERSTAND THE NEEDS OF YOUR PATIENT POPULATION

After you have identified your patient population, you should hire and deploy a Community-Based Interviewer (CBI) to conduct 10-15 in-depth interviews with patients who meet your program’s eligibility criteria. Your CBI should be an individual from the local community – exceptional listening skills are a must. The CBI should meet with patients in a comfortable setting (ex: in their own living rooms and kitchens), and ask open-ended questions about their experience with health care.

Once the interviews are complete, look for patterns in patient’s answers by analyzing the transcripts using qualitative analysis software. If you do not have this software available, carefully read through transcripts in order to identify patients’ ideas about what:

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Makes it hard for them to stay healthy They would most enjoy about working with a CHW Qualities a CHW needs to have to make them feel comfortable

We also recommend interviewing: Community-based organizations who can provide perspective on the

same questions answered by high-risk patients themselves Clinicians at sites where you will embed CHWs to help you determine the

most seamless way to integrate CHWs into routine care

The Penn Center for CHWs has created a Participatory Action Research (PAR) manual to provide guidance on conducting and analyzing these interviews.

SET UP WORKFLOW AND REPORTING SYSTEM

The Penn Center for CHWs has created HOMEBASE, a cloud-based, secure workflow CHW documentation and reporting system that maps seamlessly to IMPaCT roles and work practices.

COORDINATORS use HOMEBASE to:

Accept referrals Generate target list of eligible patients

CHWS use HOMEBASE to:

• Find patients on target list to offer IMPaCT• Capture patient information, goals and follow up notes

MANAGERS use HOMEBASE to:

Review patient records and provide supervision Generate reports to track patient care and CHW performance

DIRECTORS use HOMEBASE to:

Monitor CHW and Manager performance and report on key outcomes

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The Penn Center for CHWs can help you license HOMEBASE, which integrates with your healthcare organization’s Electronic Medical Record (EMR) and generates automatic reports used by each member of your team:

• Coordinators need to be able to generate target lists of eligible patients. A sample target list is included in the Appendix.

• CHWs need a weekly workplan that contains a snapshot of info for all the patients they’re currently working with (e.g. contact info, end date, Roadmaps). A sample of a CHW weekly workplan, or ‘next steps’ report, is included in the Appendix.

• Managers need real-time information about what’s happening with current patients (e.g. percent of Roadmaps resolved, recent hospital admissions) as well as aggregate data on closed patients to evaluate CHW performance. A sample of individual CHW performance, or ‘progress report’ is included in the Appendix.

• Directors need to be able to view different ‘slices’ of performance data to spot dips in performance. These performance views include individual (e.g. 1 CHW), team (e.g all CHWs who report to a common Manager) and program (e.g. all CHWs). A sample individual view, or 360-degree view, is included in the Appendix. Program level data can be summarized into quarterly scorecards you share with stakeholders including healthcare leadership, clinic partners, and philanthropy.

CALCULATE RETURN ON INVESTMENT

After you have identified your outcomes of interest and patient population, you should work with your health system’s finance team to build a cost savings model. On the savings side, you will need to make projections on anticipated targets for each outcome (e.g. your CHW program will reduce 30-day hospital admissions by 25%) and work with your organization’s finance team to monetize those goals based on things like average cost savings or incentive payments. You will compare this to the annual cost of running your CHW program. We’ve provided a sample annual budget in the Appendix to this manual.

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BUILDING YOUR TEAM IMPaCT is a human resource innovation. One of the most important things you will do as Director is recruit, hire and train the right people for your CHW program. The tools you need for building your team – including everything from interview questions to evaluation grids – can be found in the Hiring Toolkit. This section covers an overview of the process for hiring and training CHWs and Managers.

RECRUIT AND HIRE

You will have better success if you approach the recruitment of your CHW team differently than you would a typical clinical or operational position. Typically, organizations weigh candidate’s credentials (where they went to school, etc.) more than their subtler qualities and traits. This approach will not work for CHW recruiting: the most important thing you’re looking for is the right personality type. Here are a few general strategies to keep in mind:

A. WHERE TO RECRUIT:

Instead of posting your job in the paper or Human Resources website, we recommend circulating it through a network of community-based organizations. Not surprisingly, this is where you will find CHWs who are natural helpers. You will need to penetrate one level down from city or countywide service organizations to advertise directly with community-level organizations (e.g. block captain associations, churches, etc) in the neighborhoods your CHW program will serve. It does not have to be incredibly time intensive, although the better your relationship is with CBOs, the more success you will have.

If you already have existing CHWs whom you value, they can attend community meetings to describe the job and answer questions. They should screen potential applicants on the spot, making note of personality traits of community members who may or may not be suitable for the job. CHWs will not be the loudest person or the church leader: they listen more than they talk and are supportive and warm individuals.

B. HOW TO SCREEN APPLICANTS

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You will mostly hire based on interpersonal skills and traits, rather than applicants’ resumes. We recommend quickly screening written applications with the following lens:

Eliminate:o Sloppy/ incomplete applicationso Applicants who provide only non-employer referenceso Applicants who refuse permission to contact prior employers

Prioritize:o Applications with extra materials such as a cover letter and/ or

resumeo Progression in career path (promotions, etc.)o Long periods of employment at each former jobo Prior experience in social service or community outreacho Professional references, preferably direct supervisors

Invite all applicants that you did not eliminate to a Meet-and-Greet, a get-to-know-you session to help you identify the applicants you want to interview. This is a great tool to help you get the best feel for the right person, by seeing how applicants interact with each other and members of your team. Information on how to set up and run a Meet and Greet is included in the Hiring Toolkit.

C. INTERVIEWING TIPS

Use the interview questions, role plays and case studies included in the Hiring Toolkit and assess applicants using the evaluation grid provided. These grids include the qualities we’ve found to be necessary for success in the CHW position; you can add or subtract things based on your local needs and what you heard in your interviews with patients (see: Building your CHW Program). If possible, include existing CHWs on your hiring team, to ensure that new hires reflect the values of the community and that team dynamics work well.

D. HIRE IN COHORTS

You will generate a lot of screening and training efficiencies by hiring a cohort of CHWs at one time. Organizations have a range of budgets – if you

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only have funding for one full time employee, start by hiring two part-time CHWs instead. They don’t need to necessarily work at the same clinical site, but having two CHWs allows each to have a partner for home visits, debriefing, and ongoing and collaborative training. It is also useful to have a substitute CHW who can provide coverage for their partner in case of a medical or personal emergency.

E. BUILD A PIPELINE FOR GROWTH AND/OR TURNOVER

Take advantage of the fact that you’re interviewing a lot of applicants to identify ‘alternate’ CHWs that you would hire in the event of growth and/or turnover. Invite these individuals to paid training. Make sure you are very explicit that they have not been hired, but you are inviting them to participate in paid training for certification given their aptitude for the role and that you may have opportunities for them in the future.

TRAIN AND CERTIFY

As noted at the outset of this manual, too many organizations overemphasize training at the expense of hiring the right people and building robust program infrastructure to support the work. That being said, training is important to orient new hires to their roles. We have developed a three-part training process for CHWs and Managers that includes classroom training, on-the-job training, and certification.

A. CLASSROOM TRAINING

You will work closely with the Penn Center for CHWs to plan trainings for CHWs and Managers. This initial training allows for close observation of new hires during their introductory period. If you observe grave concerns during training (attendance, punctuality, interpersonal skills) and have provided coaching during the training that has not improved performance, you should terminate at this point to protect patients.

B. ON THE JOB TRAINING

After training, CHWs and Managers should start working with patients and CHWs, respectively. CHWs should be accompanied by a Senior CHW or their Manager when working directly with patients during this period. CHWs

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typically need 2-3 weeks to complete their on-the-job training; Managers will need approximately 6 weeks. Each new hire needs to pass checkpoints, or demonstrations of their proficiency in core areas (See ‘Certification’ below). If a new CHW or Manager is struggling in a particular area, extend their training period to provide additional support.

C. SIGN OFF

As Director, you can sign off on CHWs and Managers to work independently after they have met the following learning benchmarks:

For CHWs:

Successfully complete the IMPaCT On the Job online training and learning assessment

Learn how to stay organized. Managers will check their binders to make sure things are in order. They’ll also make sure CHWs are keeping themselves organized with to-do-lists and appointment calendars

Pass quizzes to make sure they’ve read and understood their manual Explain their role to other members of the care team Pay close attention to safety protocols and remember to text in/out

during home visits at least three times in a row. A senior CHW will observe each new CHW doing his/her work for a

full day. The senior will follow along with their manual and make sure the new CHW is getting things right.

After the senior CHW has signed off on a full day of observation, Managers will do the same.

Finally, the Director will observe each new CHW for one full day and make sure they are following the manual.

For Managers:

Successfully complete the IMPaCT On the Job online training and learning assessment

Learn how to stay organized. You’ll check their system for keeping track of appointments and daily tasks and their computer folders for organizing documents.

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Pass quizzes to make sure they’ve read and understood the CHW and Manager manuals

Explain their role and the program at a clinic meeting Pay close attention to safety protocols and pass a safety check when

a CHW is on a home visit Facilitating a team meeting Preparing all deliverables to support CHWs in their work with

patients (these are listed in the ‘detailed responsibilities’ section of the Manager manual)

You will observe each new Manager for one full day (including observation of Running the List) to make sure they are following the manual

The IMPaCT online training and certification system helps you keep track of these benchmarks. Once all these benchmarks have been met, the Penn Center for CHWs will certify individual CHWs and Managers.

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MAINTAINING A HIGH-QUALITY CHW PROGRAM

OVERVIEW OF RESPONSIBILITIES

Now that you have hired and trained your team, you can turn your attention to day-to-day operations. This section of the manual outlines your role as Director in maintaining and sustaining a high-quality CHW program, including how you:

1. Provide organizational leadership 2. Achieve annual outcomes3. Keep the manuals fresh4. Ensure CHW safety

PROVIDE ORGANIZATIONAL LEADERSHIP

Your job as Director is to inspire, troubleshoot, and coach. You will provide organizational leadership through five strategies, reviewed in detail below.

A. DIRECT COMMUNICATION WITH CHWS

It’s important that you don’t rely solely on your Managers for information on how things are going. It’s natural for people to filter information out based on what they care about, so you need a direct linkage to the CHWs themselves. Set aside an hour each week to have coffee with a CHW and meet with Senior CHWs once a quarter. Keep the agenda unstructured and follow their lead about what they want to talk about.

B. INVEST IN YOUR CORE MANAGER TEAM

While CHWs are the star of any CHW program, Managers play a critical role in ensuring CHW safety, quality patient care, and clinical integration. Your hiring process helped you identify Managers who are deeply committed to helping the most vulnerable patients. However, unlike CHWs, Managers

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don’t get the ‘win’ of directly helping patients. To keep your Managers motivated and engaged, follow these three strategies:

Meet with each Manager one-on-one biweekly to hear what’s going well and what they are worried about. Review and discuss their deliverables so you stay up-to-date with how their CHWs are doing.

Meet with your team of Managers biweekly to:o Share information about organizational priorities and updateso Provide feedback from your review of weekly reportso Give public recognition for hard worko Create space for Managers to share challenges and brainstorm

solutions

Once a quarter, schedule a half-day meeting or “boot camp” with Managers to reinforce program goals and hone their skills. You can make the meetings fun and purposeful by creating themes (e.g., “Back to the Basics”), including outside speakers (e.g., healthcare finance person to talk about the shift from fee-for-service to value-based purchasing) and having an experienced Manager facilitate a session (e.g. Manager pro tips for Running the List) on the agenda

A recommended calendar of meetings is included in the Appendix to thismanual.

C. ORGANIZATIONAL DRILLS

Organization is a key skill for all four roles in the organization. Without strong organizational skills, it is hard to keep track of the myriad tasks each job demands. At least once a year, dedicate time as a whole organization to reinforce, or ‘drill’, the importance of being organized. Involve everyone across your whole CHW program. Here is a step-by-step for how to run a fun, program-wide drill that helps to reinforce good organizational habits.

Pick a 2 to 3-week window when you have time to dedicate to this organization-wide exercise. Block time on your calendar each day specifically for the organization drill.

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Discuss the purpose and logistics of the drill at a full team meeting. Make it clear that everyone, from the CHWs to you as Director, will be focused on this skill at the same time.

Create checkpoints based on what you know works (e.g. CHWs following the organizational system outlined in their manual) but allow people to modify their checkpoints if they’ve developed a system that works better for them (e.g. keeping track of appointments and tasks on their phone or tablet). Sample checkpoints for each role in the organization, including you as Director, are included in the Appendix.

Run the drill for a set period of time (2-3 weeks is good). To reinforce organization, ask Managers to report on their CHWs’ performance each day by 5pm. You will also keep track of Manager, Coordinator and your own performance each day.

Make note of Managers who don’t send their checkpoints as well as places where CHWs are struggling (e.g. not consistently writing appointments on their calendar). Encourage Managers to observe struggling CHWs to figure out why things aren’t happening. Check in after a few days to see if there has been progress. You should also observe Managers and Coordinators who are not consistently meeting their checkpoints.

At the end of the drill, schedule a debrief session where you share your learning and encourage others to reflect. Synthesize and share coaching tips for individuals who struggled during the drill.

D. OFFER CAREER LADDERS

You worked hard to hire talented CHWs and Managers and so you will want to retain them. People stay in jobs for a variety of reasons, including connection to the mission, work/life balance, and positive feedback, among others. Another important factor is the opportunity for professional growth and financial advancement, or a career path. While it may seem that you have a career path in your organization (e.g. CHWs can grow into Managers and Managers into Directors), this is not usually the case because:

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CHWs often are not interested in being Managers because that would take them away from what they love (working directly with patients)

You hired people based on specific traits and those traits don’t always translate to the position that is ‘next in line’ (e.g. a Manager who provides great oversight of patient care may not be the best fit to lead an entire organization)

There aren’t as many Manager jobs as there are CHWs (or Director jobs as there are Managers)

For these reasons, it’s helpful to develop steps along a career ladder within the CHW or Manager role. To flesh out these positions, you should:

Use focus groups or other participatory processes to get CHW and Manager input on the kinds of work they would want to take on and criteria for advancement

Consider how some positions can be structured differently (e.g. a slightly lower caseload for Senior or Lead CHWs) so they can retain their connection to work they love while also taking on projects in a priority area such as advocacy or training

Incorporate caseload and salary changes into your Return on Investment analysis to ensure financial sustainability

Develop easy-to-read position descriptions and selection criteria. For the latter, consider both tenure (e.g. how long they’ve been with the organization) and performance

A sample CHW Career Ladder is included in the Appendix.

E. LEAD SYSTEM INTEGRATION

The IMPaCT model gains efficiencies by centralized supervision and infrastructure. However, running a centralized program that sits ‘apart’ from each clinical site runs the risk of operating in a silo. The onus is on you to make sure your CHW program works for your clinical partners and is well-integrated. Your Managers will be working at the care team level to ensure smooth integration and communication, and your job as Director is to

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provide regular updates to health system leadership so the program retains its connection to your healthcare organization’s strategic objectives. Meet quarterly with Chief Medical Officers and other leadership to get feedback on how integration is working, provide outcomes data on your CHW program, and learn about strategic objectives that may guide future program expansion.

ACHIEVE ANNUAL OUTCOMES

As Director, you will spend most of your time managing the organization to achieve the outcomes you set for your CHW program. You will work closely with your team of Project Managers to achieve your program’s goals. The two main drivers for achieving your year-end goals are to:

(a) meet your annual caseload targets and (b) ensure CHWs do high-quality work with patients

Below, we review each of these in detail.

A. MEET YOUR ANNUAL CASELOAD TARGETS

To meet your annual caseload targets, you need to develop quarterly and weekly enrollment targets that you adjust monthly as the year progresses. Here are the steps to do this:

Work with your Coordinator to determine the number of eligible patients at each of your clinical sites. Divide up your CHWs so that they each cover 1-2 clinical sites. Distribute them based on total patient eligible patient volume (e.g. assign 2 CHWs to a practice that has 1,000 eligible patients a year, and 1 CHW to a practice that only has 500).

Divide each CHW’s annual caseload target into quarterly targets. Have CHWs pick up slightly more than one-quarter (25%) of their enrollment targets in the first half of the year so you have some cushion when unplanned hiccups (ex: medical leave) arise, as it inevitably will! A sample is below:

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Inpatient CHWs

Target caseload

Q1 (Projection)

Q2 (Projection)

Q3 (Projection)

Q4 (Projection)

Projected Annual %

Projected annual

caseload John 75 27% 27% 23% 23% 100% 75Jessica 75 27% 27% 23% 23% 100% 75Maria 75 27% 27% 23% 23% 100% 75Ebony 75 27% 27% 23% 23% 100% 75Total 300 300

Caseload Targets: start of year

Break down quarterly projections into weekly enrollment targets (sample below). Your total weekly target for each clinical site should be no more than 50% of the eligible patient volume to account for things like patient refusals and no shows. For individual CHWs, avoid bunching patient pick-ups so their caseload remains nice and steady.

CHWs Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Etc… TotalJohn 1 2 2 2 1 21

Jessica 2 1 2 1 2 21Maria 1 2 2 2 1 21Ebony 2 1 1 2 2 21Total 6 6 7 7 6 84

Weekly enrollment targets at Union Hospital

Each month, meet with your Managers and the Coordinator to adjust the weekly enrollment targets for the rest of the quarter to ‘make up’ any weekly goals that weren’t met and adjust your annual projections to account for unplanned absences. Below is an example of how you would modify your caseload targets midway through the year if you found out that CHW Maria needed to be out for the last 12 weeks of the year for surgery and recovery.

Inpatient CHWs

Target caseload

Q1 (Actual)

Q2 (Actual)

Q3 (In progress)

Q4 (Projection)

Projected Annual %

Projected annual

caseload John 75 27% 27% 26% 26% 106% 80Jessica 75 27% 27% 26% 26% 106% 80Maria 75 27% 27% 28% 0% 82% 62Ebony 75 27% 27% 26% 26% 106% 80Total 300 300

Caseload Targets: mid-year update

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B. ENSURE CHWs DO HIGH-QUALITY WORK WITH PATIENTS

Each week your Managers prepare reports that assess their CHWs’ performance in a different way: phone calls to patients, performance dashboards, detailed chart reviews and frequency of patient contacts (see: ‘Manager manual: detailed responsibilities’). Block time on your calendar at least biweekly to review 15-20% of these reports. When Managers and/or CHWs are new (e.g. in their first six months on the job), you should review these reports weekly so you catch and address performance issues. Look for the following things in your review:

Individual patient-level issues were handled correctly and resolved

To make sure Managers are supervising CHWs effectively, look for the following things when you notice that a CHW made a mistake:

o Did the Manager catch the error? (e.g. during a Supervisor call, a patient said they wished they saw their CHW more. Did the Manager pick up on this and identify a next step?)

o Did the Manager develop a clear action item? (for the example above, did the Manager ask the CHW to do a home visit to that patient in the next 3 days?)

o Did the CHW follow through? (is there documentation in HOMEBASE that the CHW completed this home visit?)

Patterns that need to be addressed more systematicallyAs Director, your role is to identify patterns in the weekly reports that reveal problems and evaluate the breadth of those problems. Patterns will typically fall into one of three categories:

o Individual CHW: If an individual CHW has poor reports a few weeks in a row (e.g. spotty contact reports, not using the Arc as seen in a chart review, a drop in Roadmaps resolved on their progress report), this is a sign that the CHW is struggling. Follow the steps outlined in the next section (See: ‘Support Managers to Improve CHW Performance’).

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o Manager: If you spot similar trends for multiple CHWs on the same team, this can mean that a Manager is having trouble identifying problems or coaching CHWs. For example, if more than one CHW on the same team isn’t meeting their caseload goals, this could mean the Manager isn’t giving her CHWs enough on-call days. Follow the steps outlined in the next section (See: ‘Support Managers to Improve CHW Performance’).

o Across-the-organization: If you see an across-the-board drop in performance, you need to move quickly as Director to get a handle on the cause of the situation and course correct. To do this, follow the steps outlined later in this section (See: ‘Leadership Action Plan’).

You should review weekly reports for problems but also for standouts. In other words, if you notice a CHW or Manager doing something extremely well, tap these individuals to train others in the organization.

C. SUPPORT MANAGERS TO IMPROVE CHW PERFORMANCE

Given that your Managers review performance data on a weekly basis, drops in performance can be noticed quickly. You can help Managers address these issues with a step-by-step approach. If you have a performance issue with one of your Managers, follow these same steps to help them get back on track. For illustrative purposes, the section includes a real-world example involving Andrea, a Manager who supervises a new CHW, Jose.

Dig into the dataAndrea just finished Jose’s monthly progress report and noticed that only a third of his patients made it to their PCP appointment within two weeks of hospital discharge. What was going on? To get more details, Andrea looked at the 18 patients Jose was currently working with. Here are two examples of what she might see:

o Scenario 1: Seven of Jose’s patients, who had already been discharged, don’t have a primary care doctor appointment scheduled.

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o Scenario 2: Five of Jose’s patients had scheduled appointments in the last two weeks, but only one of the five made it to their appointment.

Talk to the CHW Andrea met with Jose the next day. She asked him generally for his thoughts about what might be going on, but also asked specifically about possible lapses in best practices, given the data:

o Scenario 1: Jose should be scheduling PCP follow-up appointments while patients are still in the hospital

o Scenario 2: Jose should be calling patients before their scheduled PCP appointments and offering to accompany them

ObserveAndrea scheduled time to watch Jose do his job in the following ways:

o Scenario 1: She went with Jose to the hospital on his next on-call day to see what was happening with scheduling PCP follow-up appointments before discharge

o Scenario 2: She and Jose called patients with upcoming appointments the next time they Ran the List

Make a planHelp managers come up with a plan to improve performance; this plan can include going back and doing a relevant training from the IMPaCT online library. Managers should set clear goals for performance improvement: in Jose’s case, the goals could be: (a) 100% of patients get pre-doctor coaching before their PCP appointment and (b) 50% of his patients attend their PCP appointment. Make sure your managers are keeping an eye on all their CHWs measures’ so that an improvement in PCP follow-up doesn’t come at the expense of other outcomes. Managers should make a 30-day plan and schedule a two-week check-in to maintain focus and motivation. A sample 30-day CHW goal plan is included in the Appendix.

Determine next steps

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Coaching to improve performance needs to go one of two ways: either mark it as a success or move forward with a formal Improvement Plan. If the final check-in goes well, the situation is resolved. However, if the results were not good, the Manager will need to move the CHW to a formal improvement plan. These are understandably difficult conversations and preparation is essential. Managers should block time before (to practice what they will say and ensure they are being clear) and after (to write up any HR documentation). Also, you should space out disciplinary meetings when possible. While it’s important to react to immediate situations as and when they happen, try not to have too many disciplinary situations happening across the organization at any given time to minimize emotional drain and reverberation through a close-knit organization.

D. LEADERSHIP ACTION PLAN

Sometimes as Director, you will see a dip in performance that’s not limited to one CHW or one Manager, but is affecting the whole team. Across-the-organization variations are the Director’s responsibility to understand and correct. For organization-wide issues, you should act quickly and create a Leadership Action Plan (LeAP), a systematic, project management plan to identify the cause of the problem and determine the best solution. For illustrative purposes, the section includes a real-world example of a drop in your 30-day hospital readmissions outcome.

Step 1: Craft a memo clearly summarizing the problem. Include supporting data.

o Sample memo

March 6th: Dear team, our 30-day readmissions for our inpatient program have worsened over the past year. While we have always had some variation in our outcomes, there has been a steady decline over the past four quarters that has me concerned (see table). Remember that we compare 30-day readmissions for patients that get a CHW to 30-day readmissions for patients that don’t get a CHW. So a negative number is a good thing: it means that CHW patients have fewer 30-day

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readmissions compared to non-CHW patients. Please come prepared to share your ideas about why this might be happening at our team meeting next week.

Q1 Q2 Q3 Q4

-27% -22% -21% -14%

30-day readmissions for inpatient program

Step 2: Take a team-based approach to help you solve this problem. Involve CHWs, Managers and Coordinators to ensure you’re seeing the problem from all angles. Generate a set of hypothesis about why the problem is happening. Test those hypotheses, and make sure this process includes observation so you can see what’s really going on.

o Updates to memo

March 14th: Dear team, thanks for all your great ideas at today’s meeting about why our 30-day readmissions outcomes have gotten worse over the past year (see table).

Q1 Q2 Q3 Q4

-27% -22% -21% -14%

30-day readmissions for inpatient program

Here are the ideas we generated, along with action items we will take:

Possible cause: Non-CHW patients are increasingly different than CHW patients (e.g. CHW patients are sicker than non-CHW patients and so come to the hospital more).

i. Coordinator will analyze these two groups to see if they are increasingly different

Possible cause: When patients are readmitted, we’re not talking to their doctor to understand what’s going on medically and what the doctor recommends we work on.

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i. Managers and the Director will each shadow 2 CHWs working with readmitted patients in the next two weeks

Possible cause: We don’t always know when patients have been readmitted.

i. Director will look into getting an alert when patients come back to the hospital

Step 3: Reconvene your team to share what you’ve learned. Decide what action items (e.g. additional training, changes to the manual, etc) you will make to address the issue.

o Updates to memo

March 28th: Dear team, thanks for a great meeting today! We’ve made a lot of progress in the last two weeks understanding what’s happening with hospital readmissions in our inpatient program (see table).

Q1 Q2 Q3 Q4

-27% -22% -21% -14%

30-day readmissions for inpatient program

Here are the notes from today’s meeting, along with next steps:

Possible cause we tested: Non-CHW patients are increasingly different than CHW patients (e.g. CHW patients are sicker than non-CHW patients and so come to the hospital more).

i. Results: Coordinator analyzed these two groups and they are not markedly different. No next steps

Possible cause we tested: We’re not talking to doctors on the day of hospital readmission to understand what’s going on medically and what they think we work on.

i. Results: Managers and the Director shadowed 8 CHWs working in the hospital last week. Only 3

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CHWs spoke to the doctor while they were in the hospital. In 2 instances the conversation was one-sided (e.g. the CHW said what they were working on but did not ask the doctor any questions). We will update the manual with a short script for talking to doctors and provide training to practice this next week. We’ll also update HOMEBASE to include a box to check after you’ve talked to the patient’s doctor

Possible cause we tested: We don’t always know when patients have been readmitted.

i. Results: We will start receiving text alerts next week for patients readmitted in the previous 12 hours

I’m excited about these changes and will provide an update at our April team meeting about how things are going in the first 30 days of making these changes. Thanks, all!

KEEP THE MANUALS FRESH

A work manual isn’t written once and then put on the shelf. Lots of times, people will have unconsciously drifted from the manual. To minimize drift, use these systems:

A. MANUAL QUIZZES

As described in the Manager manual, Managers should ask a question from the CHW manual each time they meet. You should do this as well during your biweekly meetings with your team of Managers. Draw questions from challenges you see from your review of weekly reports and ask Managers to reflect individually on the correct answer. After a minute, have someone share the answer and then discuss the rationale. Collect the pieces of paper (names aren’t necessary) and review them to see how many people had the correct answer.

B. MANUAL REVIEW

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Set aside one team meeting each quarter to review the manual soup to nuts. Review the manual section-by-section, stopping to reinforce the rationale for why the program does things a particular way (e.g. CHWs approach patients the day of their admission to maximize the time they can work with them in the hospital). Spend most of your time reviewing areas where observation has revealed drift from best practices.

C. DESIGN JAMS

Once every few years, the Penn Center for CHWs will provide updated work manuals that contain the latest best practices from our evidenced-based research and design. In between these updates, you should meet with your full team of CHWs, Managers and Coordinators to see what isn’t working and brainstorm improvements to address those challenges. We call these organization-wide brainstorm sessions Design Jams. In the first year of your CHW program, conduct Design Jams at least once every six months to understand what’s not working and iron out kinks. After that, you can conduct one per year.

D. DESIGN SWEEPS

After each Design Jam, you should follow a systematic process to make sure the changes you made are absorbed across the organization. This should include:

Updating manuals to reflect the new procedures Making changes in HOMEBASE, as necessary Training all CHWs, Managers, and Coordinators Asking a question about the new procedures at team meeting (e.g.

manual quizzes for CHWs, Managers, and Coordinators) Observing CHWs for fidelity to new processes

ENSURE CHW SAFETY

The most important principle of a CHW program is that CHW safety comes first. Being a CHW can be a dangerous job. Your most important role as a Director is to ensure the safety of your team.

In the event that a CHW feels unsafe working with a patient, their Manager will call a

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Safety Huddle that day to discuss what to do. As Director, you will run this Safety Huddle and ultimately determine if/how a CHW can work safely with a patient. Here are tips for running an effective Safety Huddle:

Get the full picture – ask the CHW to describe who the patient is as a person, what they’re working on, and the source of their safety concern. Have the Manager share relevant information from the EMR (e.g. access to a weapon, history of violence, things that might impair the patient’s judgment like mental health, substance abuse or dementia)

Summarize the facts to make sure you didn’t miss anything Ask each person, starting with the CHW, what they recommend based on what

they’ve heard Try to come to consensus but be prepared to make the final decision if the group

does not agree Ask the Manager to summarize the meeting and send daily updates until all

safety-related action items are resolved

These are the guidelines for safety included in the CHW and Manager manuals:

WHAT TO DO IF YOU FEEL UNSAFE:

• Trust your gut and talk to your Manager: If a patient behaves inappropriately or makes you feel uncomfortable or unsafe, or if you experience any threat to your health (e.g. bedbugs) call your Manager. If you are really scared, call 911.

• Safety huddle: Once you report a safety issue to your Manager, you, your Manager and the Director will have a safety huddle THAT DAY to discuss what to do.

• After safety huddles, the Director may call a safety meeting to brainstorm our policies and work practices to avoid future safety issues.

SAFETY WHEN PICKING UP AND WORKING WITH PATIENTS

• If CHWs realize early on that they know a patient personally, are related to the patient, or live in the same 1-2 block radius as the patient, they should not work with this patient.

• Never tell a patient where you live.

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CHW GUIDELINES FOR HOME VISITS:

WHO: Home visits will be made in teams of two. If you are not familiar with the neighborhood, go with someone who is. If you are not crossing the threshold of the home, you can go alone but text your Manager that you are ‘SOLO’ and strongly consider taking a buddy anyway.

WHAT TO DO BEFORE A HOME VISIT: CHWs should be prepared before leaving for a home visit. Run through this checklist:

• Did you document the time and location of this visit on your calendar? Is the location services device on your phone on? Does someone know where you are?

• Do you have transportation? Do not use your bicycle as this can make you a target.

• Do you have clear directions and a contact number for the patient in your phone?

• Did you call the patient prior to leaving the office, to make sure that the patient is expecting you?

• Do you have charged cell phones? • Do you have your work ID badge? • Do you have your binders and patient forms/scripts that you need?

WHAT TO DO DURING A HOME VISIT:

• Keep your IDs visible• Always text in and out to your Manager as you cross the threshold of

the home. If you don’t feel safe texting outside, you can wait until you are inside but use the threshold as your cue to remember. Think about ‘loading’ your text in advance so that all you have to do when you cross the threshold is to hit send.

• If you are not entering the home and are alone, text ‘SOLO’ so that your Manager checks on you within 30 minutes instead of one hour.

• Aside from texting in and out, don’t use your phone or computer on the street or on public transportation because this can make you look like a snitch or a target for theft.

• Leave if you feel uncomfortable. Once you feel safe, call the patient and reschedule.

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• Never enter a patient’s car or give them a ride.• Try not to be totally alone with a patient unless you are in public. This

protects you from harm and accusation.• Keep your phone’s location services feature on at all times in the

event that we need to locate you in a safety emergency. Your tracking password is kept in a central, secure folder and only used by Managers with Director permission in situations of serious concern for your safety.

WHEN: Home visits should be made in the daytime. The exact times may vary depending on the time of year.

WHERE: CHWs should make every effort to do visits at patients’ homes. However, if they have concerns about visiting a patient’s home, they can use a neutral place nearby instead such as a community center or a church.

If you are out in the community and encounter an unsafe area (i.e. a block with active gunfire etc.) let your Manager know immediately and add this to the patient’s safety note. Your Manager will notify the Director, who will communicate this information to the rest of the team. Use your best judgment when considering future home visits in this area, and don’t go if you don’t feel safe. Home visits to blocks with past safety issues should always be done with caution, and always with a buddy until you assess that the risk has passed.WHY: When done safely, meeting patients in their homes and communities is a crucial part of your job. It makes things easier for patients, and helps the CHWs learn even more about their patients’ lives.

ADDITIONAL NOTES FOR MANAGERS:

• When a CHW texts in to let you know they are on a home visit, set your alarm for 1 hour. If it’s a solo visit (i.e. without a buddy) set an alarm for 30 minutes. If you can’t reach your CHW after your alarm goes off, call the Director. You will try to locate the CHW using the location services device on their phone and may end up calling the police to do a check of wellness.

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• If the Director decides to terminate a patient from the program because of a safety threat, Managers must document this clearly at the top of ‘Safety Notes’ section in HOMEBASE. This alerts the Coordinator, who may otherwise end up re-enrolling the patient in the future.

• Make sure your CHWs’ location services login information is up-to-date in the organization’s central, secure repository.

Any violation of the Safety Rules will result in immediate disciplinary action (verbal warning, then a written warning with human resources involvement). CHWs should report any breaches of safety to the Manager or Director.

INFECTION & INFESTATION PREVENTION:

Well-being is an important aspect of safety. Below you will find some information that can help protect you from bedbugs and MRSA.

Protecting Yourself from Bedbugs

Bed bugs are small, reddish-brown bugs that can grow up to the size of an apple seed. They are usually visible to the eye.

Bed bugs move from place to place in luggage, clothes, boxes, and used furniture – or through small cracks between apartments.

They only come out at night – but leaving a light on won’t stop them from biting.

Bites from bed bugs cause large, itchy bumps on some people. Other people don’t have any reaction to the bites.

When in all patients’ homes, CHWs should:

* Place your coat, bag and outer wear in an area clear of patient belongings or clutter.

* Avoid sitting on beds or furniture that is upholstered or made of wood.

* Wear clothing that can be washed and dried at high temperatures.

If you find out your patient has bed bugs at their home:* Inform your Manager and include this information in the

HOMEBASE ‘Safety Note’

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* We will never require you to do a home visit if you feel unsafe, but it is possible to do safe home visits to homes with bed bugs if you take the precautions listed above

If you find out your patient has bed bugs in their hospital room:* Inform your Manager and the hospital team

If you think you have been exposed to bed bugs:* As soon as possible, wash all clothing and personal items in very

hot water for at least 15 minutes and dry the items on high heat for at least 30 minutes.

* Clothing that cannot be subjected to high temperatures should be soaked in warm water with lots of detergent for several hours.

* Clothing that cannot be laundered may be steam cleaned.

If you are worried you may have brought bedbugs home with you:

* Check items you brought into patient’s homes for signs of bedbugs. Items to check include clothing, tablets, briefcases, rolling bags and backpacks. Check carefully along fabric seams.

* Check yourself for signs of bedbug bites.

* Check your bedding and mattress (particularly along seams), upholstered and wooden furniture, moldings and wall cracks. A flashlight is helpful when examining these items for signs of bedbugs.

* Talk to your Manager if you find a bed bug in your home

Bedbugs can be embarrassing and stressful. If you are working with a patient with bedbugs, be kind. Create Roadmaps to address things they may need or want (ex: talking to their doctor about itchiness and other systems; resources for extermination)

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Protecting Yourself from MRSA

MRSA is a type of bacteria that is very common in the community. Lots of people have it just living on their skin and it doesn't cause problems. In some people it can cause boils. Rarely, usually if someone is already sick, it can cause more serious illness like pneumonia.

In the hospital, when someone has MRSA we use gowns/gloves/masks, to decrease the chance that one of us (a healthcare provider) will pass the MRSA to a sick patient who could get ill from it. Outside of the hospital (in clinics and community), gowns/gloves/masks are not recommended.

Outside the hospital, the main tool for preventing MRSA is hand hygiene. Hands should be cleaned thoroughly with soap and water or an alcohol-based hand sanitizer, immediately after touching the skin or any item that has come in direct contact with a draining wound. If you have any wounds that are draining (like a cut or a sore) you should keep it covered with clean, dry bandages. Avoid touching any open wounds that a patient might have without wearing gloves. Don't share personal items that you have used such as towels, clothing, bedding, bar soap, razors, or athletic equipment that touches the skin. Consider changing your clothes each day you get home in the evening after work and taking a shower. You can wash all your work clothes in hot water on the weekend and then they are fine to use again.

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APPENDICESBUILDING A CHW PROGRAM

SAMPLE ANNUAL BUDGET

WORKFLOW AND REPORTING TOOLS

TARGET LIST FOR COORDINATORS

NEXT STEPS REPORT FOR CHWS

PROGRESS REPORT FOR MANAGERS

360 DEGREE PERFORMANCE VIEW FOR DIRECTOR

MAINTAINING A HIGH-QUALITY CHW PROGRAMORGANIZATIONAL DRILL CHECKPOINTS

CHW CAREER LADDER

CHW 30-DAY GOAL PLAN

RECOMMENDED WEEEKLY CALENDAR

Director Manual

APPENDICESBUILDING A CHW

PROGRAM

Director Manual

SAMPLE BUDGET

PersonnelRole on Project Annual Salary

Benefit Rate Percent Effort Total

CHW #1 (new hire) 34,680$ 35% 1.0 46,818$ CHW #2 (new hire) 34,680$ 35% 1.0 46,818$ CHW #3 (new hire) 34,680$ 35% 1.0 46,818$ CHW #4 (new hire) 34,680$ 35% 1.0 46,818$ CHW #5 (new hire) 34,680$ 35% 1.0 46,818$ CHW #6 (new hire) 34,680$ 35% 1.0 46,818$ CHW #7 (new hire) 34,680$ 35% 1.0 46,818$ CHW #8 (new hire) 34,680$ 35% 1.0 46,818$

Manager # 1 52,000$ 35% 1.0 70,200$ Manager # 2 52,000$ 35% 1.0 70,200$ Coordinator 36,000$ 35% 1.0 48,600$

Director 80,000$ 35% 0.5 54,000$

Personnel Total 11.5 617,544$ Equipment

Monthly Cost

Number of

Months Quantity TotalTeam member expenses

Smartphones, inclduing aircards 60$ 12 12 8,640$ Laptops 1,500$ One time 12 18,000$

CHW transportation 100$ 12 8 9,600$ CHW gym memberships 30$ 12 8 2,880$

Patient expensesPatient supplies 200$ 12 2,400$

Patient transportation 100$ 12 1,200$ Organizational expenses

Ongoing training 300$ 12 3,600$ Meeting expenses 100$ 12 1,200$

Office supplies 250$ 12 3,000$

Equipment Total 50,520$ Total annual cost 668,064$ Per patient cost 1,113$

CHW Program Annual BudgetIntensive CHW care for 600 patients/year

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TARGET LIST FOR COORDINATORS

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NEXT STEPS REPORT FOR CHWS

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PROGRESS REPORT FOR MANAGERS

Director Manual

360 DEGREE PERFORMANCE VIEW FOR DIRECTORS

Director Manual

APPENDICES MAINTAINING A HIGH-

QUALITY CHW PROGRAM

Director Manual

ORGANIZATIONAL DRILL CHECKPOINTS

CHWs

Prints calendar in morning Writes down when they say they are going to do something Enters notes within 24 hours Records home visits and other appointments on their calendars Reviews to-do list and adds new appointments to calendar at end of day (Was there any instance where they did not do something they say they would do?)

Managers

Passes safety check (1 Manager per week) Writes down when they say they are going to do something Responds to all emails within 24 hours Sends agenda within 24 hours of supervision Completes action items from agenda on time (Was there any instance where they did not do something they say they would do?)

Coordinators

Writes down when they say they are going to do something Responds to all emails within 24 hours Sends agenda within 24 hours of supervision Completes action items from agenda on time (Was there any instance where they did not do something they say they would do?)

Director

Responds to all emails within 24 hours Completes action items as scheduled On time for all meetings (Was there any instance where they did not do something they say they would do?)

Director Manual

CHW CAREER LADDER

CHW

Salary: $17/hour Responsibilities

o See ‘Job Announcement – Community Health Worker’ Selection criteria

o See ‘Evaluation Guidelines – Community Health Worker’

SENIOR CHW

Salary: $19.25/hour Additional Responsibilities

o Participates in hiring process for new CHWs and Managerso Acts as a spokesperson in the communityo Helps train new CHWs and Managers o Can take on long-term initiatives (e.g. advocacy or training) with up to 15% caseload

reduction Promotion criteria:

o At least 3 years as a CHWo Consistently meet job expectationso Recommended by Managero Approved by Director

LEAD CHW

Salary: $22/hour Additional Responsibilities

o Acts as a spokesperson at conferences and with the media o Mentors other CHWso Leads short-term projectso Can take on long-term initiatives (e.g. advocacy or training) with up to 15% caseload

reduction Promotion criteria

o At least 6 years as a CHWo Consistently meet job expectationso Serves as a role model and leader in the organizationo Recommended by Manager

Director Manual

CHW 30-DAY GOAL PLAN

CHW name: RebeccaToday’s date: 2/15

AREAS TO IMPROVE Lower your refusal rate. 1 out of 2 patients you meet in the hospital say ‘no’ to the program Improve your hustle. Only 1 of your last 6 patients had a Roadmap completed in the first 3 days

GOALS 3 out of 4 patients you meet in the hospital say ‘yes’ to the program You complete one ‘Do It Now’ Roadmap when you meet patients. This will create momentum.

MANAGER SUPPORT Role play common scenarios when meeting new patients when we Run the List on 2/17 Brainstorm ‘Do It Now’ Roadmaps for five new patients when we Run the List on 2/17 Set a time for you to shadow CHW Maria, who has the highest ‘yes’ rate of all CHWs (week of 2/22)

CHECK INS March 1: Two week check in agenda

o Hear from you how things are goingo Review how many patients said ‘yes’ to program since 2/15o Review how many ‘Do It Now’ Roadmaps you completed for patients picked up since 2/15o Revise our plan, if necessary, to offer additional support

March 15: Final check in o Review how many patients said ‘yes’ to program since 2/15o Review how many ‘Do It Now’ Roadmaps you completed for patients picked up since 2/15o Decide on next steps

Director Manual

RECOMMENDED CALENDAR

All meetings are weekly unless otherwise noted

Monday Tuesday Wednesday Thursday Friday

9am Coffee with CHW

10am

11am

noon

1pm Meet with admin Team meeting

2pm

3pm

4pm

5pmSafety huddle (as

needed)

Manage caseload targets (monthly)

Other: e.g Manager bootcamp, clinical

leadership meeting, manual review

(quarterly)

1:1s with Managers/meet with

all Managers (alternate weekly)

Follow up on Manager action items

Observation Thinking and writing

Project work

Deliverable review and follow up

NOTES

1. Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over outpatient care. Health Aff (Millwood). Jul 2013;32(7):1196-1203.

2. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80-94.3. Armstrong K, McMurphy S, Dean LT, et al. Differences in the patterns of health care system distrust between blacks

and whites. J Gen Intern Med. Jun 2008;23(6):827-833.4. DHHS. Community Health Worker National Workforce Study In: U.S. Department of Health and Human Services

Health Resources and Services Administration BoHP, ed. Washington, D.C. March 2007.5. Balcazar H, Rosenthal EL, Brownstein JN, Rush CH, Matos S, Hernandez L. Community health workers can be a public

health force for change in the United States: three actions for a new paradigm. Am J Public Health. Dec 2011;101(12):2199-2203.

6. Thoits PA. Stress, coping, and social support processes: where are we? What next? J Health Soc Behav. 1995;Spec No:53-79.

7. Bone LR, Mamon J, Levine DM, et al. Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers. Am J Emerg Med. Jan 1989;7(1):16-20.

8. Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. May 2007;32(5):435-447.

9. Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med. Mar 20 2012;156(6):416-424.

10. Adair R, Christianson J, Wholey DR, et al. Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease. J Ambul Care Manage. Jan-Mar 2012;35(1):27-37.

11. Viswanathan M, Kraschnewski J, Nishikawa B, et al. Outcomes of community health worker interventions. Evid Rep Technol Assess (Full Rep). Jun 2009(181):1-144, A141-142, B141-114, passim.

12. Sherwen LN, Schwolsky-Fitch E, Rodriquez R, Horta G, Lopez I. The community health worker cultural mentoring project: preparing professional students for team work with health workers from urban communities. J Allied Health. Spring 2007;36(1):e66-86.

13. Viswanathan M, Kraschnewski JL, Nishikawa B, et al. Outcomes and costs of community health worker interventions: a systematic review. Med Care. Sep 2010;48(9):792-808.

14. Richter RW, Bengen B, Alsup PA, Bruun B, Kilcoyne MM, Challenor BD. The community health worker. A resource for improved health care delivery. Am J Public Health. Nov 1974;64(11):1056-1061.

15. Kangovi S, Barg FK, Carter T, et al. Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition. J Gen Intern Med. Aug 6 2013.

16. Kangovi SG, D.; Carter, T.; Barg, F.; Rogers, M.; Glanz, K.; Shannon, R.; Long, J.A. . The use of participatory action research to design a patient-centered community health worker care transitions intervention Healthcare: The Journal of Delivery Science and Innovation. In press, 2013.

17. Kangovi SL, K.; Barg.F; Carter, C.; Long, J.A.; Grande, D. Post-hospital syndrome among older adults of low socioeconomic status J Health Care Poor Underserved. 2013;Pending.

18. Kangovi S, Grande D, Meehan P, Mitra N, Shannon R, Long JA. Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. Nov-Dec 2012;7(9):709-712.

19. Redding M, Redding, S. . Community Health Access Project: Pathways Building a Community Outcome Production Model. 2010; http://chap-ohio.net/. Accessed August 2nd, 2012.

20. MacGregor K, Wong S, Sharifi C, Handley M, Bodenheimer T. The action plan project: discussing behavior change in the primary care visit. Ann Fam Med. Jul-Aug 2005;3 Suppl 2:S39-40.

21. Rimer, K. & Brewer, N. (2014) Introduction to health behavior theories that focus on Individuals. In Health Behavior: Theory, Research, and Practice, edited by Karen Glanz, et al., Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/upenn-ebooks/detail.action?docID=2082957. Downloaded from upenn-ebooks on 2018-01-04 09:59:40.

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