High-Risk Populations

Every day in hospitals and clinics across the country, healthcare providers do their best to help patients get healthy. But patients often struggle because of real-life challenges such as job pressure, trouble paying for medications, hunger or trauma. These real-life challenges are concentrated in low-income communities. That is why it is no surprise that these "hot-spot" communities often have the worst metrics on things that health systems care about: hospital readmission, chronic disease control, etc.

In 2010, researchers from Penn Medicine and its community partners decided to speak with the experts: high-risk patients themselves. Our team interviewed hundreds of chronically-ill or hospitalized patients living in a hot-spot and asked for their ideas for improving health care.

I can't get what I need from the clinic so I have to go to the ER.

We are being set up to fail.

They can give you advice, like here's the kind of medicine you need. But they don't really know how it works in the real world.

Patient Perspectives

Patients explained that they were being driven to the hospital because of barriers to obtaining high-quality primary care. They also felt that doctors were often "setting us up to fail" by setting health goals that were unrealistic given socioeconomic constraints.

Patients felt a sense of disconnect from nurses, doctors, social workers, and even case managers who often came from very different backgrounds. Patients wanted support from someone to whom they could relate, who would not judge them, someone who had "been there." They wanted help with the real-life challenges that were making them sick.

It turns out that a powerful solution was already in their own backyard.

Community Health Workers

Community health workers (CHWs) are people who share life experience with the patients whom they serve. They come from similar neighborhoods, speak the same language, share race and culture. They have "been there". And they are natural helpers: the type of people who bring soup to a sick neighbor or look in on an elderly friend on a hot summer day.

Many other countries around the world have incorporated CHWs into their health care workforce because they are inexpensive, yet can be effective in improving the health of the most marginalized individuals. It is easy to understand why organizations in the United States are becoming increasingly excited about the CHW worforce.

Yet, despite this potential, many of the CHW programs that have existed in the United States have proven ineffective or unsustainable.

Our team wanted to harness the great potential of the CHW workforce, while avoiding the pitfalls.

Designing a Successful CHW Model

Researchers from our Center studied past failures and determined that five key elements would help CHW programs succeed in the future:

  1. Hiring guidelines to decrease turnover
  2. Clear work practices to promote productivity
  3. Patient, not disease-centered care, to allow for scale
  4. Integration of CHWs into health care systems for sustainable financing
  5. High-quality scientific evidence to ensure results

Penn Center for Community Health Workers

We worked with patients, caregivers and clinicians to create IMPaCT™, a comprehensive, evidence-based CHW model that incorporates each of these five key CHW program elements. In 2013, the Penn Center for Community Health Workers was created to advance the integration of evidence-based CHW models into healthcare delivery.

Since our creation, we've worked to improve the health of high-risk patients through the effective use of Community Health Workers by:

Patient Care

  • Providing the infrastructure to translate IMPaCT from research to routine practice for Penn Medicine's highest risk patients. We grew from six full-time employees to our current staff of 50. Most employees are CHWs who provide health system navigation, social support and advocacy to more than 2,000 high-risk UPHS patients annually.


  • Receiving a 3-year, $1.5 million grant from the Patient-Centered Outcomes Research Institute. This grant funds a multi-center randomized controlled trial (including the Veterans Affairs Administration and a federally qualified health center) to evaluate the effect of IMPaCT on chronic disease management.


  • Working with leadership of the Perelman School of Medicine to develop a novel medical student elective called the IMPaCT Teaching Service. In this rotation, medical students serve as apprentices to CHWs for 2-4 weeks and learn about community engagement and the social determinants of health. The Center's founder and Executive Director, Dr. Shreya Kangovi, was awarded a plenary presentation at the Society of General Internal Medicine National Meeting to discuss the IMPaCT Teaching Service as an important innovation in medical student education.


  • Providing training and technical assistance to selected organizations and disseminating our toolkit for program implementation to more than 800 organizations across the country.
  • Presenting our work to state and national audiences at events organized by the Society of Internal General Medicine, the Annie E. Casey Foundation, the PA Department of Health, the Network for Excellence in Health Innovation and the Jewish Healthcare Foundation.

Learn about IMPaCT, our CHW model