a multi-center trial of impact chw support for chronically-ill patients

Conditions: Hypertension; Diabetes; Obesity; Tobacco Dependence

Summary: this is a multi-center randomized controlled trial comparing the effectiveness of community health worker (chw) vs. usual clinician support in helping chronically-ill patients with low socioeconomic status to improve their health outcomes.

community health workers (chws) have the potential to improve chronic disease outcomes among patients with low socioeconomic status (ses). yet, widespread use of chws has been hampered by lack of standardized, scalable and evidence-based models. our community-academic-health system team used participatory action research with low-ses patients to design impact (individualized management for patient-centered targets). a randomized controlled trial (rct) of 446 hospitalized patients with varied diseases demonstrated that a 2-week dose of impact improved access to care, mental health, activation, and quality of communication, while reducing recurrent hospital readmissions. we have adapted impact for use among low-ses primary care patients with multiple chronic conditions. this rct is designed to evaluate the newly adapted impact model in 3 primary care settings - academic, federally qualified health center, and va. upon enrollment in the trial, patients will collaboratively set a chronic disease management goal with their primary care provider. patients will then be randomized to collaborative goal-setting versus goal-setting augmented by 6 months of support from an impact chw. follow-up will be conducted at 6- and 9- months post-enrollment. the study design is a single-blinded, 2- armed, multi-site randomized controlled trial involving three clinic sites and 444 patients.

Eligibility criteria:
inclusion criteria: * patient of specific practice (mutch/st.leonards court, spectrum, pvamc) for at least 1 yr defined as having one office visit within preceding 12 months * resident of home zip code including any of the following 19104, 19131, 19139, 19142, 19143, 19145, 19146, \& 19151 * has 2 or more of the following conditions: 1. obesity: bmi30 2. htn: icd9 relating to htn from emr problem list or emr icd9 encounter diagnosis x2) 3.dm: icd9 relating to dm from emr problem list or emr icd9 encounter diagnosis x2) 4. tobacco (from epic social history/vital signs) * has at least one poorly controlled condition based on the most recent value prior to enrollment: obesity (bmi\>=35); htn (sbp \>= 160); dm (hgba1c \>=9); tobacco use (\>0 cigarettes)" * is uninsured, insured by medicaid, or dually eligible for medicare and medicaid or va insurance * has a scheduled appointment at a study clinic in the future. * community health workers/chws/impact partners involved in the care of patients of the three practices will be included in the qualitative portion of this study. exclusion criteria: * will not provide informed consent for this study. * does not have the capacity to provide informed consent for this study. * previously enrolled in this study. * currently enrolled in another study focusing on chronic disease management. * currently has a chw * no one will be excluded on the basis of sex or race.