An Emerging Model for Community Health Worker–Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia

Authors: Crespo, R., Christiansen, M., Tieman, K., and Wittberg, R.
Year: 2020
State: NatDoc: National Document
Website link:
Publicly Available: Yes
Billing and Reimbursement: Expand evidence base
Evidence Generation:
Sustainable Financing: CMS and CDC engagement from a national level, Engaging state partners in general, Expand evidence base, General other, MCO or bundled payment reimbursement models, Documentation of how CHWs can work within care teams, Evidence-based interventions, ROI and bundled payment successes/challenges
Workforce Development: CDC expand CHW work into SDOH, Chronic Disease, Data sharing between social services and clinical teams, General other (including mention of “employment practices”)

Community health workers (CHWs) can improve patients’ health by providing them with ongoing behavioral support during the health care experience, and they help decrease health care costs, especially among patients whose starting costs are high and among underserved and minority populations. We developed a CHW-based care model with the aim of improving outcomes and lowering costs for high-risk diabetes patients in rural Appalachia. Enrolled patients experienced a mean decrease in HbA1c of 2.4 per- centage points, and 60% or more of patients with diabetes lowered their blood glucose between baseline and 6 to 12 months after enrollment. As health care providers and patients became familiar with this model of care management, enrollment in the program accelerated.

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