ABSTRACT
Community health workers (CHWs) have worked in a variety of settings in the United States for more than 70 years and are increasingly recognized as an essential health workforce. CHWs share life experience with the people they serve and have firsthand knowledge of the causes and impacts of health inequity. They provide a critical link between marginalized communities and health care and public health services. Several studies have demonstrated that CHWs can improve the management of chronic conditions, increase access to preventive care, improve patients' experience of care, and reduce health care costs. CHWs can also advance health equity by addressing social needs and advocating for systems and policy change. This review provides a history of CHW integration with health care in the United States; describes evidence of the impact of CHW programs on population health, experience, costs of care, and health equity; and identifies considerations for CHW program expansion.
Subject(s)
Health Equity , Public Health , Humans , United States , Community Health Workers , Delivery of Health CareABSTRACT
OBJECTIVE: The aim of this study was to evaluate the effectiveness of a digital health intervention plus community health worker (CHW) support on self-monitoring of blood glucose and glycosylated hemoglobin (HbA1c) among adult Medicaid beneficiaries with diabetes. DESIGN: Randomized controlled trial. SETTING: Urban outpatient clinic. PARTICIPANTS: Adult Medicaid beneficiaries living with diabetes and treated with insulin and who had a HbA1c ≥ 9%. INTERVENTION: Participants were randomly assigned to one of three arms. Participants in the usual-care arm received a wireless glucometer if needed. Those in the digital arm received a lottery incentive for daily glucose monitoring. Those in the hybrid arm received the lottery plus support from a CHW if they had low adherence or high blood glucose levels. MAIN MEASURES: The primary outcome was the difference in adherence to daily glucose self-monitoring at 3 months between the hybrid and usual-care arms. The secondary outcome was difference in HbA1c from baseline at 6 months. KEY RESULTS: A total of 150 participants were enrolled in the study. A total of 102 participants (68%) completed the study. At 3 months, glucose self-monitoring rates in the hybrid versus usual-care arms were 0.72 vs 0.65, p = 0.23. At 6 months, change in HbA1c in the hybrid versus usual-care arms was - 0.74% vs - 0.49%, p = 0.69. CONCLUSION: There were no statistically significant differences between the hybrid and usual care in glucose self-monitoring adherence or improvements in HbA1C. TRIAL REGISTRATION: This trial is registered with clinicaltrials.gov identifier: NCT03939793.
Subject(s)
Diabetes Mellitus, Type 2 , Diabetes Mellitus , Adult , Humans , Blood Glucose , Glycated Hemoglobin , Blood Glucose Self-Monitoring , Community Health Workers , Diabetes Mellitus, Type 2/therapyABSTRACT
BACKGROUND: Socioeconomic data may improve predictions of clinical events. However, owing to structural racism, algorithms may not perform equitably across racial subgroups. Therefore, we sought to compare the predictive performance overall, and by racial subgroup, of commonly used predictor variables for heart failure readmission with and without the area deprivation index (ADI), a neighborhood-level socioeconomic measure. METHODS AND RESULTS: We conducted a retrospective cohort study of 1316 Philadelphia residents discharged with a primary diagnosis of congestive heart failure from the University of Pennsylvania Health System between April 1, 2015, and March 31, 2017. We trained a regression model to predict the probability of a 30-day readmission using clinical and demographic variables. A second model also included the ADI as a predictor variable. We measured predictive performance with the Brier Score (BS) in a held-out test set. The baseline model had moderate performance overall (BS 0.13, 95% CI 0.13-0.14), and among White (BS 0.12, 95% CI 0.12-0.13) and non-White (BS 0.13, 95% CI 0.13-0.14) patients. Neither performance nor algorithmic equity were significantly changed with the addition of the ADI. CONCLUSIONS: The inclusion of neighborhood-level data may not reliably improve performance or algorithmic equity.
Subject(s)
Heart Failure , Patient Readmission , Academic Medical Centers , Heart Failure/diagnosis , Heart Failure/epidemiology , Heart Failure/therapy , Humans , Residence Characteristics , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Capturing and incorporating patient-centered factors into 30-day readmission risk prediction after hospitalized heart failure (HF) could improve the modest performance of current models. METHODS: Using a mixed-methods approach, we developed a patient-centered survey and evaluated the additional predictive utility of the survey compared to a traditional readmission risk model (the Krumholz et al. model). Area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow goodness-of-fit statistic quantified the performance of both models. We measured the amount of model improvement with the addition of patient-centered factors to the Krumholz et al. model with the integrated discrimination improvement (IDI). In an exploratory analysis, we used hierarchical clustering algorithms to identify groups with similar survey responses and tested for differences between clusters using standard descriptive statistics. RESULTS: From 3/24/2014 to 3/12/2015, 183 patients hospitalized with HF were enrolled from an urban, academic health system and followed for 30days after discharge. The Krumholz et al. plus patient-centered factors model had similar-to-slightly lower performance (AUC [95%CI]:0.62 [0.52, 0.71]; goodness-of-fit P=.10) than the Krumholz et al. model (AUC [95%CI]:0.66 [0.57, 0.76]; goodness-of-fit P=.19). The IDI (95%CI) was 0.003 (-0.014,0.020). We identified three patient clusters based on patient-centered survey responses. The clusters differed with respect to gender, self-rated health, employment status, and prior hospitalization frequency (all P<.05). CONCLUSIONS: The addition of patient-centered factors did not improve 30-day readmission model performance. Rather than designing interventions based on predicted readmission risk, tailoring interventions to all patients, based on their characteristics, could inform the design of targeted, readmission reduction strategies.
Subject(s)
Heart Failure , Patient Readmission/statistics & numerical data , Patient-Centered Care/methods , Aged , Area Under Curve , Cluster Analysis , Comorbidity , Demography , Female , Heart Failure/epidemiology , Heart Failure/therapy , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Patient Discharge , ROC Curve , Risk Assessment/methods , Risk Factors , Socioeconomic Factors , Surveys and Questionnaires , United StatesABSTRACT
BACKGROUND: Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse. OBJECTIVES: In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management. RESEARCH DESIGN: We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation. SUBJECTS: Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation. RESULTS: We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down." CONCLUSIONS: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.
Subject(s)
Chronic Disease/therapy , Community Health Workers/organization & administration , Health Behavior , Patient Compliance/statistics & numerical data , Adult , Community Health Services/methods , Female , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Poverty , Treatment OutcomeABSTRACT
BACKGROUND: Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient's experience may reframe the readmission "problem" and, ultimately, inform alternative strategies. OBJECTIVE: To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission. DESIGN: Observational qualitative study. PARTICIPANTS: Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission. APPROACH: Open-ended, semi-structured interviews. Conclusions vetted using focus groups. KEY RESULTS: Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients' home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a "negative" outcome. CONCLUSION: Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.
Subject(s)
Attitude to Health , Heart Failure/therapy , Home Care Services , Patient Readmission/statistics & numerical data , Adult , Aged , Aged, 80 and over , Choice Behavior , Emotions , Female , Focus Groups , Heart Failure/psychology , Hospitalization/statistics & numerical data , Humans , Interviews as Topic , Male , Middle Aged , Patient Compliance/statistics & numerical data , Patient Outcome Assessment , Philadelphia , Qualitative Research , Socioeconomic Factors , Treatment FailureABSTRACT
OBJECTIVES: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. METHODS: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. RESULTS: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. CONCLUSIONS: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01900470.
Subject(s)
Community Health Workers/organization & administration , Mental Health , Multiple Chronic Conditions/therapy , Poverty , Vulnerable Populations , Adult , Aged , Blood Pressure , Body Mass Index , Female , Glycated Hemoglobin/analysis , Health Status , Humans , Male , Middle Aged , Philadelphia , Quality of Health Care/organization & administration , Single-Blind Method , Smoking/epidemiology , Socioeconomic FactorsABSTRACT
BACKGROUND: Although substantial effort has been devoted to reducing readmissions among heart failure (HF) patients, little is known about factors identified by patients and caregivers that may contribute to readmissions. The goal of this study was to compare the perspectives of HF patients, their caregivers, and their care team on HF management and hospital admissions. Understanding these perspectives may lead to better strategies for improving care during the post-hospital transition and for reducing preventable readmissions. METHODS AND RESULTS: We performed freelisting, an anthropologic technique in which participants list items in response to a question, with hospitalized HF patients (n = 58), their caregivers (n = 32), and clinicians (n = 67). We asked about home HF management tasks, difficulties in managing HF, and perceived reasons for hospital admission. Results were analyzed with the use of Anthropac. Salience indices (measures of the most important words for defining the domain of interest) were calculated. Patients and clinicians described similar home HF management tasks, whereas caregivers described tasks related to activities of daily living. Clinicians cited socioeconomic factors as challenges to HF management, whereas patients and caregivers cited limited functional status and daily activities. When asked about reasons for hospitalization, patients and caregivers listed distressing symptoms and illness, whereas clinicians viewed patient behaviors to be primarily responsible for admission. CONCLUSIONS: These findings highlight that although some similarities exist, there are important differences among patients, caregivers, and clinicians in how they perceive the challenges of HF management and reasons for readmission. Understanding these differences may be critical to developing strategies to reduce readmissions.
Subject(s)
Caregivers/psychology , Disease Management , Heart Failure/psychology , Heart Failure/therapy , Patient Satisfaction , Physician's Role/psychology , Adult , Aged , Aged, 80 and over , Female , Heart Failure/diagnosis , Humans , Male , Middle Aged , Surveys and QuestionnairesABSTRACT
Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.
Subject(s)
Academic Medical Centers/organization & administration , Community Health Workers/organization & administration , Poverty , Research Support as Topic/organization & administration , Academic Medical Centers/economics , Chronic Disease/economics , Chronic Disease/epidemiology , Community Health Workers/economics , Health Services Accessibility/organization & administration , Humans , Patient Satisfaction , Primary Prevention/organization & administration , Program Evaluation , Research Support as Topic/economicsABSTRACT
PURPOSE: Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODS: We conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).] RESULTS: The interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff. CONCLUSIONS: Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.
Subject(s)
Patient-Centered Care/organization & administration , Vulnerable Populations , Adult , Communication , Female , Health Services Accessibility , Humans , Male , Medicaid , Medically Uninsured , Middle Aged , Office Visits , Professional-Patient Relations , United StatesABSTRACT
BACKGROUND: Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients. OBJECTIVE: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals. APPROACH: Our interview guide investigated patients' perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis. KEY RESULTS: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors. CONCLUSIONS: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.
Subject(s)
Continuity of Patient Care/economics , Health Behavior , Insurance Coverage/economics , Medicaid/economics , Medically Uninsured , Patient Discharge/economics , Adolescent , Adult , Aged , Aged, 80 and over , Continuity of Patient Care/trends , Female , Humans , Insurance Coverage/trends , Male , Medicaid/trends , Middle Aged , Patient Discharge/trends , Social Support , Socioeconomic Factors , United States/epidemiology , Young AdultABSTRACT
Importance: Community health worker (CHW) programs may improve health outcomes, increase quality of life, and reduce hospitalizations and cost of care. However, knowledge is limited on the barriers and facilitators associated with scaling evidence-based CHW programs to maximize their public health outcomes. Objective: To identify barriers and facilitators to implementing an evidence-based CHW model. Design, Setting, and Participants: This qualitative study examined perspectives of Individualized Management of Person-Centered Targets (IMPaCT) program staff (health system leaders, program managers, and community health workers) and patients receiving the intervention between March 9, 2020, and July 22, 2021, at 5 institutionally and geographically diverse health systems across the US. The collected data were analyzed between December 1, 2021, and April 27, 2022. Program staff were recruited via purposive sampling, and patients were recruited via convenience sampling. Intervention: The disease-agnostic IMPaCT CHW model includes a standardized implementation approach and a structured set of theory-informed intervention components to create and achieve individualized action plans. Main Outcomes and Measures: Interview guides were informed by the Consolidated Framework for Implementation Research. A rapid qualitative analytic technique was used to identify key themes, which were categorized into barriers and facilitators associated with framework ecological domains. Results: Of a total 41 individuals invited, 39 agreed to participate (95% response rate; mean [SD] age, 45.0 [12.6] years; 30 women). General barriers included economic and policy constraints, including insufficient funding for CHW programs, clinical integration challenges, and CHW difficulty with maintaining boundaries. Program-specific barriers included insufficiently tailored materials for certain populations and upfront and ongoing program costs. General facilitators included CHWs' interpersonal skills and life experiences. Program-specific facilitators included the model's strong evidence base, supportive implementation team, and program design that enabled relationship building and engagement. Additional themes were cited as both barriers and facilitators, including the COVID-19 pandemic, organizational leadership, IMPaCT training, and program fidelity. Conclusions and Relevance: These findings suggest growing recognition of the importance of CHWs to improving health equity and population health. Barriers identified point to important policy and practice implications for CHW programs more broadly, including the need for continued attention to improving clinical integration and the need for sustainable program financing to preserve the longevity of this workforce.
Subject(s)
COVID-19 , Community Health Workers , Humans , Female , Middle Aged , Community Health Workers/education , Pandemics , Quality of Life , COVID-19/epidemiology , Qualitative ResearchABSTRACT
BACKGROUND: Conventional immunosuppressive therapy for primary pediatric focal segmental glomerulosclerosis (FSGS) is potentially toxic and only moderate evidence supports its effectiveness. Renin-angiotensin-aldosterone (RAAS) inhibition monotherapy is anecdotally used in selected patients as an alternative to conventional therapy. METHODS: We performed a retrospective cohort study of children with primary FSGS seen at a tertiary care academic hospital between 1986 and 2008. We classified patients into two groups based upon initial treatment: RAAS inhibition monotherapy (RIM) and conventional therapy (CT). The primary endpoint was progression to end-stage renal disease (ESRD). Secondary endpoints were remission of proteinuria, relapse, and death. RESULTS: The cohort consisted of 67 patients. Mean baseline urine protein/creatinine ratio (Up/c) was 8.0 (5.2, 10.7) mg/mg, and mean baseline estimated glomerular filtration rate (eGFR) was 115.0 (101.8, 128.1) mL/min/1.73 m(2). Patients in the RIM group were more likely to have lower eGFR (100.8 mL/min/1.73 m(2) vs 132.9 mL/min/1.73 m(2), p = 0.01) and less proteinuria (4.4 vs.14.4, p < 0.01). Renal failure occurred in 22.9% of the RIM group vs 40.6% in the CT group (log-rank p = 0.07). After adjustment for African-American race, time period of presentation, baseline age, eGFR, and Up/c, patients in the RIM group had a 0.11 hazard ratio of progressing to renal failure compared with patients in the CT group (p < 0.01). CONCLUSIONS: Children treated initially with RIM may have better outcomes than those treated with CT.
Subject(s)
Glomerulosclerosis, Focal Segmental/drug therapy , Renin-Angiotensin System/drug effects , Adolescent , Blood Pressure , Child , Cohort Studies , Female , Glomerular Filtration Rate , Humans , Immunosuppressive Agents/therapeutic use , Kaplan-Meier Estimate , Kidney Function Tests , Male , Proteinuria/etiology , Renal Insufficiency/etiology , Retrospective Studies , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. METHODS: The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. CONCLUSION: The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.
ABSTRACT
Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.
Subject(s)
Community Health Workers , Medicaid , Delivery of Health Care , Humans , Investments , Socioeconomic Factors , United StatesABSTRACT
OBJECTIVE: To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING: Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN: The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS: The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS: Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS: Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.