Kim Tieman, Vice President & Program Director, Claude Worthington Benedum Foundation
Guided by its mission of “helping people help themselves,” the Claude Worthington Benedum Foundation strategically invests in the creative problem-solving activities of local communities and individuals. For the past decade, the Benedum Foundation has accomplished this mission in its support of a particular health care delivery model: efficient chronic disease management through a medical model leveraging the skills of community health workers (CHW) in Appalachia. This model provides unique patient care, has shown success for improving the health conditions of a target population, and reduced health care costs—accomplishments that align with the Institute of Health Improvement’s Triple Aim framework.
An understanding of CHWs as a flexible workforce providing specific services in a variety of settings is imperative to understanding this health care delivery innovation, referred to as the CHW integrated chronic care management (CCM) model. The model leverages CHW skills in a medical model, as compared to other models where a CHW might assist with insurance enrollment. The model has three essential elements: a health care provider serving as a champion, weekly team “huddles” where patients’ social determinants of health and medical condition treatment goals are reviewed, and weekly CHW home visits—the latter being “through the door, not to the door.”
Reviewing the model’s early implementation, its initial success was a result of focusing on patients with Type 2 diabetes. With time, the model has proved transferable to other medical conditions: obesity, congestive heart failure, chronic obstructive pulmonary disease, hypertension, long COVID, and high-risk youth. It has also proved beneficial for pregnant and parenting women with substance use disorder.
In addition to addressing specific medical conditions, the model has also been scaled to a variety of clinical settings. For example, Drug Free Moms and Babies sites in three states, multiple Federally Qualified Health Centers (FQHCs), free clinics, and most recently, academic medical centers.
For the past several years, the model demonstrates consistent positive results for measurable health outcomes, costs, and quality of life measures. It is now a proven financially self-sustaining model for practice sites who use it with attention to fidelity. Examples of specific outcomes include strengthened chronic care management, increased compliance with care plans, enhanced community-clinical linkages, strong relationships between CHWs and patients, improved self-management of chronic diseases along with reduced emergency department visits and dramatic decreases in hospitalizations.
The Benedum Foundation initially provided grant support for model startup, but also served as the strategic convenor of providers, payers, and an academic partner to be present at the same table. Over time, this engagement allowed all partners a first-hand observation of the model’s growing sustainable successes as it was implemented in multiple settings for many medical conditions. With replication, these partners learned together what model elements were most integral to successful scaling—documenting and disseminating not only what does work, but also what does not—and taking away an understanding that model fidelity is mandatory for success.
Payors initially agreed to cover home visits. However, as the model matured, and the value of integrating the CHW into chronic care management among their members was recognized by payors, the interaction between providers and payors changed. Payors now collaborate with providers to mutually identify high-risk patients and engage with the payor’s case managers.
It is important to recognize the unique value provided by the academic partner. From the start, Marshall University has proved vital to the model’s success. In its educational role, the university provides CHW training and education for clinical teams. For site administrators and coding and billing teams, it provides ongoing technical assistance. Because data collection is also imperative for any pay for success model, Marshall’s team helped practice sites leverage the REDCap data tool and embedded performance management and quality improvement measures that aligns with other routine data collection. The university also provides each site with a monthly review of their Healthcare Effectiveness and Data Information System (HEDIS) measures. Lastly, the university team provides multiple other unique services that not only relieve practice sites of complex data analysis but ensures the model’s integrity and fidelity. That latter offering is important as the model expands to new target populations and sites.
The Benedum Foundation, in its philanthropic role of supporting this CHW-integrated CCM model through its decade of growth, has also been a key partner. As a long-term investor and a convenor, the Foundation’s involvement was strategic in engaging the three managed care organizations now using an established payment structure to sustain the model’s use by practices. Early in the model’s development, the foundation also participated in a public-private partnership grant—a partnership that realized the potential of effectively blending philanthropy and government funding streams to achieve a sustainable pay for performance model.
Like other health funders, The Benedum Foundation is interested in supporting communities as they not only discover and address the root causes of health inequities but implement innovative projects that have long-lasting impact. The support of such projects, such as the CHW-integrated CCM model, demonstrates clearly that innovation and cross-sector partnerships through the work of philanthropy are worth the time and effort.