Quick overview of IMPaCT™
© 2014 The Trustees of the University of Pennsylvania. All Rights Reserved.
Dr. Kangovi presents an overview of the IMPaCT model.
© 2014 The Trustees of the University of Pennsylvania. All Rights Reserved.

Our Model

In the IMPaCT™ model, community health workers provide tailored support to help high-risk patients achieve individualized health goals. IMPaCT has been adopted by the University of Pennsylvania Health System as part of routine care for over 3,000 high risk patients. IMPaCT was built in response to the question: "What do patients want?" Our team conducted hundreds of interviews with patients and analyzed this data. We then created IMPaCT recruitment, training, care, and integration systems in order to address challenges reported by patients, using their suggestions.

Recruitment

Patients wanted a relationship with a health care provider 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 have a nonjudgmental nature, the ability to "take time and listen", to "work with people and have patience."

We have developed human resources guidelines including behavioral and case interviews designed to help identify individuals from within patients' communities who have the traits patients are looking for.

IMPaCT

Training

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

We have designed a month-long college-accredited training program that teaches CHWs to address each of these types of issues that patients described.

Model: Set Goals, Support, Connect

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. They then help patients to create tailored action plans or Roadmaps towards reaching their goal.
  • Support: CHWs provide tailored support to help patients achieve their goals. This may mean exercising with patients at the local YMCA, helping to coordinate doctor's appointments, or providing emotional support through a difficult time.
  • Connect: The hardest part of any intensive support model is the ending. Patients often lose ground after an intervention ends. IMPaCT CHWs work to transition patients to a soft landing. For recently hospitalized patients, this means getting them into a primary care practice that can meet their needs. IMPaCT CHWs transition outpatients to a weekly support group 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.

IMPaCT

Integration

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

  • Organizational directors: These are the people who want to take the lead in running a CHW program at their institution. The manuals provide guidance on important topics like patient selection, business models, and stakeholder engagement.
  • Managers: These are the people (typically social workers) who will be directly supervising CHWs. The manual provides guidance on topics like day-to-day supervision practices, on-going training, avoiding burnout, and integration with health care teams.


Hover over boxes to see team member bios.
Jill Feldstein, MPA
Director

I believe in the power of strong and caring relationships to move people to action. I witnessed this time and time again when I worked as a community organizer and I see it on a daily basis with Community Health Workers and their patients. That trusting relationship enables patients to tackle some of their toughest challenges. I am proud that our work improves people’s lives and that we continue to quantify that improvement to demonstrate the value of integrating Community Health Workers into mainstream healthcare.

Casey Chanton, MSW
Manager

I am a social worker with a background in community organizing and trauma-informed practice. I came to work with the Penn Center for Community Health Workers because I believe that people who come from within a community are uniquely equipped to support and advocate for patients from that community. I have seen Community Health Workers build deep and trusting relationships with our patients and advocate for them fiercely; this can impact a patient’s life and health in ways both small and profound.

Tamala Carter
Interviewer

I am community-based interviewer with the University of Pennsylvania Mixed Methods Research Laboratory. I have a background in Community Outreach. Prior to coming to Penn, I worked at the Enterprise Center, CDC with the Walnut Hill Street Team, canvassing door-to-door in the Walnut Hill community. Since joining Penn, I have worked as a Community-Based Interviewer, conducting hundreds of low-income patients from West Phildelphia in the hospital and in their homes for various research projects. I was involved in the development of the IMPaCT Transitions model which helps patients make the transition from hospital to home. I believe that the role of Community Health Workers is of great importance to patients and their doctors as the CHW serves as the link that connect the two. The goal of determining how to provide patients with the best care possible motivates me to be a part of research projects and to help write scientific articles that give voice to high-risk patients.

Robyn Smith, BA
Coordinator

I am the coordinator for the Penn Center for Community Health Workers. I am passionate about health equity and community empowerment and I am honored to be part of such a dedicated team of staff. I am excited to continue working towards producing quality research , which I hope in the future will aid in the development of evidenced based best practices that may lead to significant improvements in patient health outcomes.

Mary White
Senior Community Health Worker

I became a Community Health Worker because I love providing support to patients to help them receive the best Health Care ever and achieve their health care goals. My favorite memory is of a patient who was uninsured and homeless. The patient had a chronic illness which required extensive medical care. Through IMPaCT I was able to help the patient get insurance, disability assistance, and find him an appropriate primary care provider and specialist. The patient was then also able to look for stable housing.

Anthony Davis
Community Health Worker

I participate as a Community Health Worker because as a leader in my neighborhood I feel it is necessary for everyone to be represented and assisted in the health care system. Navigating the system can become complicated and in my experience, having assistance makes it easier for my neighbors to get healthier with less aggravation.

Cheryl Garfield
Community Health Worker

I am a Community Health Worker on the Transitions Team. I wanted to become a CHW to make a difference in people’s lives by helping them stay healthy. My favorite memory so far is helping a patient get into safe housing.

Randy Hastings
Community Health Worker

I feel a need to reach out to my community and provide one on one personal support for those who need it. Moreover, I strongly believe that Community Health Workers help to close a void that exists within our medical system. It gives me pride, when I use my skills and compassion to fight for those who are struggling with life issues.

Irene Estrada
Community Health Worker

I became a community health worker because I have a passion for encouraging people to meet their goals! I am by my patients side: going for walks, introducing them to and attending free nutrition classes at the YMCA, and picking out healthy food choices. IMPaCT brings healthcare out of the hospital and into people's homes and communities: the rec centers, grocery stores, churches, wherever the patient is.

Our Team

One of the keys to getting good results from a CHW program is to have appropriate staffing ratios and caseloads. Our team has experimented with these parameters and developed an optimal team structure.

A Director and Community-based Interviewer can serve eight CHW Teams. Each CHW team is composed of one Manager, a half-time time Coordinator, and 8 CHWs (6 CHWs and 2 Senior CHWs).

Because IMPaCT is not disease or setting-specific, the CHWs within a given team can be spread across different practices or settings.

It may be hard to understand what an IMPaCT CHW team looks like just by reading about it. So, we wanted you to meet our team to get the feel of who we are and how we function. On the image to the left, hover over our interactive team structure to meet each team member and learn about their job descriptions.


Watch a video overview of the IMPaCT Transitions program (2011)

Stories

The program was wonderful. My IMPaCT Partner went out of his way to help with things that were above and beyond. He helped me to get insurance and doctor's appointments. He became a friend and was very helpful.

46 year old uninsured woman who relied on emergency room for COPD and hypertension care

My CHW was excellent. I was having issues dealing with stuff about my mom and she helped me get counseling. She has been great and a big help with everything.

20 year old woman with persistent asthma who recently lost her mother

I had to go to the hospital four times in the first six months of 2011. I had recently lost my job and my purpose in life. I spent the days chain-smoking. During a hospital stay I met Mary, an IMPaCT CHW. She was so warm and easy to talk to. She turned me on to a community center in our neighborhood and helped me get a quit-smoking patch. It has been nearly 2 years, and I haven't had a cigarette. I teach music at the community center. I feel like I have a home there now.

60 year old man with COPD

I love Sharon! She referred me to programs that offer me boxes of food because that is a problem that I face.

65 year old woman with asthma, a pacemaker, and mechanical heart valve

She has a strong gift for reaching people, making them want to live better. It helps you to help yourself.

52 year old man in recovery for substance abuse

She said "whenever you need anything just call".

48 year old woman with neurofibromatosis and seizure disorder

I wanted to share with you a wonderful thing that happened during our rounds today. When I introduced Cheryl to our team, our new attending said, "Cheryl, are you from the IMPaCT team? I know of you, but not sure how."

Our humble, modest Cheryl says, "Dr. Norris I worked with you and Ms. Jackson." The commitment, passion and genuine concern Cheryl had for Ms. Jackson can only be described as truly a monumental changing of a life. Ms. Jackson is cognitively impaired and kept coming into the hospital with recurrent infections. During one of these hospitalizations, she was connected with IMPaCT and met Cheryl. Cheryl stayed with our patient, until she was safe in a special housing situation (she had been living in an abusive situation where the owner of the home was taking all of her money) that gave her regular meals, (having not eaten on weekends for years, and going to churches for free meals,) helped with her medicine adherence and more than anything else gave her a new sense of well-being and trust in people.

Dr. Norris is Ms. Jackson’s outpatient doctor. She jumped up from the table ran to Cheryl and thanked her profusely and hugged her in front of our whole team. My heart was so full for Cheryl. She works so hard, is so committed to this work and all the patients who are so blessed to have her assistance. She knows so much about so much, I learn new things from her everyday.

She is symbolic of the highest standards of patient advocacy and the best our health system offers its patients. I was so happy to see her get a small acknowledgement of all she does during our rounds by the one person who really understood the importance and meaning of her work for this patient. This is the most wonderful work I have ever done and feel honored, blessed, and proud to work with such incredibly passionate genuine CHW's.

Randi Jackson, MSOD, BSN, RN CNOR; Penn Presbyterian Medical Center Chief Service Care Coordinator, practicing nurse of 30 years.