Creating Systems Change to Improve Patient Outcomes through Collaboration: From Community-based Health Intervention to Health Care System Implementation and Policy Change

Healthcare reform has called for systems change and attainment of the “triple aim”- better health, better quality, and lower health care costs. One strategy recognized in the Affordable Care Act (ACA) and progressively being discussed by medical providers and policy-makers is the utilization of Community Health Workers (CHWs) as valued members of healthcare teams.  Community-based interventions involving the CHW model are shown to be effective at enhancing service delivery through more efficient, patient-centered care. The ACA’s promotion of new models of care delivery and financing has provided opportunity for CHWs to become financially sustainable partners within healthcare systems.

In 2014, Advocate Physician Partners (Advocate) partnered with the Sinai Urban Health Institute (SUHI), an expert in CHW model implementation, to create a program intended to improve the health of Advocate’s high risk, Medicaid patients.  During the yearlong collaboration, SUHI provides strategic support concerning the CHW model, how best to integrate CHWs into the health system, and implementation of SUHI’s Asthma CarePartners (ACP) program, a 12-month CHW asthma intervention.  This partnership is a “train the trainer” knowledge transfer approach, wherein at the conclusion Advocate will have the capability to launch and maintain a CHW program.  Anticipated outcomes of the ACP program are a 60% reduction in symptom frequency and a 70% reduction in asthma-related health resource utilization.

Novel approaches like this collaboration that focus on systems change to improve patient outcomes and ultimately affect health administration polices is the future of healthcare reform and a sound method for implementing the triple aim.