An Emerging Model for Community Health Worker–Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia
IMPLEMENTATION EVALUATION — Volume 17 — February 13, 2020
PEER REVIEWED
The CHW-Based CCM model consists of 3 vertical boxes on the left-hand side, depicting referrals from health care providers of their high-risk patients. Arrows point to a box in the center that represents the care management team. This team is represented by a mid-level provider, a nurse, and community health workers. Below this box is a list of the functions of the care management team. These are: risk assessment, patient enrollment, develop a care plan, conduct weekly case reviews, and follow up with the primary care provider. Arrows from this box point to 3 vertical boxes on the left that depict interventions done in the community. The box on the top has community health worker assistance with ancillary and social services. The box in the middle has weekly community health worker home visits. The box on the bottom has involvement of patients in community events such as diabetes self-management education, diabetes self-management programs, gardening, and walking.
Figure 1.
Organizational structure of the chronic care management team, implementation of community health worker–based chronic care management, rural Appalachia, United States, 2017–2019. Abbreviations: CHWs, community health workers; DMSE, diabetes self-management education; DMSP, diabetes self-management program; NP, nurse practitioner; PA, physician assistant; PCP, primary care provider.
Figure 2.
Enrollment in a community health worker–based chronic care management program, rural Appalachia, United States, 2017–2019.
Month and Year | No. of patients |
---|---|
May 2017 | 4 |
June 2017 | 18 |
July 2017 | 22 |
August 2017 | 26 |
September 2017 | 30 |
October 2017 | 38 |
November 2017 | 40 |
December 2017 | 53 |
January 2018 | 67 |
February 2018 | 79 |
March 2018 | 94 |
April 2018 | 124 |
May 2018 | 140 |
June 2018 | 165 |
July 2018 | 177 |
August 2018 | 204 |
September 2018 | 221 |
October 2018 | 295 |
November 2018 | 331 |
December 2018 | 357 |
January 2019 | 404 |
February 2019 | 444 |
March 2019 | 485 |
April 2019 | 529 |
May 2019 | 567 |
June 2019 | 617 |
July 2019 | 651 |
August 2019 | 690 |
September 2019 | 729 |
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