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Related Experiment Videos

Achieving IHI's Triple Aim by Utilizing Core Health Program With Community Health Workers in Rural Communities.

Kenneth J Fawcett1, Raymond K Neff, Christina M Freese Decker

  • 1Spectrum Health Healthier Communities, Spectrum Health Hospital Group, Grand Rapids, Michigan (Drs Fawcett and Neff); Spectrum Health, Grand Rapids, Michigan (Ms Freese Decker); and Spectrum Health Hospital Group, Greenville, Michigan (Ms Faber).

Family & Community Health
|August 23, 2018
PubMed
Summary

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A nurse/community health worker team model improved health outcomes and reduced care costs for underserved patients with heart failure and/or diabetes in rural areas. This managed care program demonstrated significant savings and fewer hospital admissions.

Area of Science:

  • Community Health
  • Healthcare Management
  • Chronic Disease Management

Background:

  • Underserved populations often face barriers to accessing consistent healthcare.
  • Heart failure and diabetes management require coordinated, multidisciplinary approaches.
  • Rural healthcare settings present unique challenges for patient care delivery.

Purpose of the Study:

  • To evaluate a nurse/community health worker team model for managing heart failure and diabetes in underserved rural populations.
  • To assess the program's impact on patient outcomes and total cost of care.
  • To determine the feasibility and return on investment of this model in rural community health.

Main Methods:

  • A 12-month managed care program was implemented for 277 underserved patients.

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  • The program utilized a collaborative nurse and community health worker team approach.
  • Evaluation employed the Institute for Healthcare Improvement's Triple Aim criteria and HEDIS measures.

    • Main Results:

    • Study participants experienced improved health outcomes.
    • A significant reduction in the total cost of care was observed.
    • Hospital admissions decreased, saving 203.4 inpatient days, with a 1.37 return on investment for ED and inpatient visits.

    Conclusions:

    • The nurse/community health worker team model is effective in improving outcomes for rural, underserved patients with heart failure and/or diabetes.
    • This integrated care approach leads to reduced healthcare costs and hospital utilization.
    • The program demonstrates a positive return on investment, supporting its scalability in similar settings.