Helping Community Health Workers Succeed: Ideas From an Innovative Program

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Mark Masselli ( 00:04 ):
Community health workers are the key to building a more equitable and fair healthcare system in
America. Is there a secret sauce for hiring them, helping them succeed and retaining them?
Dr. Shreya Kangovi ( 00:14 ):
Community health workers are not a new workforce. They are 300 year old workforce. And one of the
most important things for us to be able to do is learn from that 300 years of history. There has been a lot
of work that's been done to advance the workforce and really importantly, to learn what are the success
factors.
Margaret Flinter ( 00:36 ):
We're talking with Dr. Shreya Kangovi, who's developed the IMPaCT Care program. It's a standardized
and scalable program that transforms the effectiveness of the community health workforce by re-
imagining each step.
Dr. Shreya Kangovi ( 00:50 ):
In the IMPaCT model, for example, we don't just train community health workers, we train the
supervisors. Because you can train somebody until they're blue in the face, but if their boss doesn't
understand their job or know how to support them, they're not going to get very far. And a lot of that
supervision, training and support is around burnout prevention and creating spaces for community
health workers to share with their peers so that they can have that outlet for some of that real
secondary trauma that they're going to experience in this role.
Margaret Flinter ( 01:20 ):
This is Conversations on Healthcare.
Mark Masselli ( 01:30 ):
Dr. Kangovi, welcome to Conversations on Healthcare.
Dr. Shreya Kangovi ( 01:34 ):
Thank you. I'm so delighted to be here.
Mark Masselli ( 01:37 ):
You've done such incredible work. You developed the Individualized Management for Patient-Centered
Targets programs known as IMPaCT Care, and the Penn Center for Community Health Workers supports
this model. Can you give our audience an overview of your approach?
Dr. Shreya Kangovi ( 01:56 ):
Absolutely. And so first of all, again, thank you for having me. I am currently the CEO of IMPaCT Care.
We spun out of the University of Pennsylvania earlier this year and are now a public benefit corporation
that's really just dedicated to scaling this work across the country.
Mark Masselli ( 02:12 ):
Congratulations.

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Dr. Shreya Kangovi ( 02:13 ):
Thank you. Thank you. And as you heard in the intro, what we get out bed to do is to remake the
American health workforce in service of equity and efficiency. And we do this by ensuring that
community health workers have every chance of success, and that requires really six things to go right.
Number one, an organization that is building a community health workforce really needs to know what
they're doing. They need to have a strategic plan to know what problems they're trying to solve, how
they want this workforce to help them address those problems, what the priority populations are, and
really how best to position the workforce within their organizational context.
( 02:57 ):
Number two, they have to hire the right people. Fundamentally, this is a human resource innovation and
it's only as good as the people who are doing the work. We help organizations do this by actually
launching hyper-local, but technology enabled recruitment campaigns that surface natural helpers who
already exist all around us in our communities, and we screen them for traits like empathy and non-
judgment and reliability. Number three, we have to train this workforce as well as their supervisors, and
that's something that we do and we have to provide ongoing professional development so that you can
really maximize retention. And then the last couple of pieces have to do with what's the day-to-day
workflows.
( 03:43 ):
You need technology enabled workflows that are grounded in social and behavioral science that help
community health workers meet people where they are and really drive meaningful change. And you
need a supervision layer that supports these community health workers, make sure that they're
advancing in their careers even as they are delivering the types of outcomes that we're all looking for.

Margaret Flinter ( 04:04 ):
Well, that is fascinating and congratulations on the new or newish organization. And I think this is
probably still true even though you've got the new organization. I understand you're an associate
professor at the University of Pennsylvania Perelman School of Medicine. Is that still correct?

Dr. Shreya Kangovi ( 04:22 ):
Well, I was a full professor and since we spun out, I'm now adjunct faculty, but my full-time role is with
IMPaCT Care.

Margaret Flinter ( 04:31 ):
All right, well great. I'm not sure if this was past or current, but I was really interested in what I'd read
that you and your colleagues were able to walk through the emergency room. A great example of going
where the patients are, unfortunately sometimes and looking to talk with and enroll patients in the
program. We're really curious, what did you say to people in that moment, in that setting and how do
they react with the opportunity to be enrolled in the IMPaCT program?

Dr. Shreya Kangovi ( 05:03 ):
So to take a step back, I mean we've been doing this work for 15 years and we've started and continued
to make sure that patients and people are at the center of everything that we do in terms of design and
execution of IMPaCT. In fact, the first piece of this 15 years ago was that a woman named Tamela Carter,
who's a community member from southwest Philadelphia. She and I partnered and interviewed 1500

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people on porches and bedsides and in emergency rooms and shelters. We asked them, what makes it
hard for you to stay healthy and what should we be doing differently?
( 05:41 ):
We use that to then design the IMPaCT model based on the answers to the questions that we were
asking folks about how they would design a community health worker program. We then rolled it out
and tested it in three separate randomized control trials and found that it did in fact move the needle on
health outcomes, like diabetes control, mental health, quality of care, and then cost of care by reducing
hospitalizations. And then we started to scale it across... At this point we're working with partners across
20 different states and in every layer of this, it does always come back to us looking somebody in the eye
and asking that person, what do you think?
( 06:25 ):
What do you want? So when an IMPaCT community health worker sits down and meets their patient for
the first time, they don't talk at them, they listen to them. And they say, what do you want to do in
order to improve your life and your health and how can I help you with that? And someone may say, "I
haven't spoken to my mother in the last five years and I really need to repair that relationship, or I need
to battle this eviction notice. Or You know what, I just want to plant an urban garden." The patient gets
to choose their own adventure and the community health worker is able to transfer that power to them.
And I think to your point, that is why people engage at such high rates.
( 07:06 ):
We have a 70% engagement rate with IMPaCT, which is a lot higher than you might have with other
[inaudible 00:07:14] programs or other case management programs. And that's because, well, who
doesn't want to be asked what they want to do and get to do that?

Mark Masselli ( 07:21 ):
I love, first of all, your six pillars that you have as sort of the foundation and then this concept to know
where you're headed, you need to know where you came from. And you really went out on the porches
and figured out where you came from. It really sort of anchored you in that community, gave you some
really important lessons learned and anything that stands out as you sort of look at that approach. And
I'm wondering, as you spread your model, are you asking people to sort of consider it?
( 07:54 ):
I know one of the things that we do at our health center is we open a new site, we go and knock on
5,000 household doors because we want to change the power dynamic so that we're in their home
sharing information versus sort of having them come in. So it sounds like a lot of empowerment's going
on in the work that you're doing, really getting a core understanding of the population that you want to
work collaboratively to make a difference.

Dr. Shreya Kangovi ( 08:23 ):
A hundred percent. This is all about, Mark, power. I believe, and I think there's a lot of science to
support the fact that when you talk about health inequity or a lot of the population health issues that
we have in this country, you can't address that with pills or vaccines or even necessarily more primary
care visits because it's not just an imbalance of disease. It really reflects an imbalance of power because
a lot of these health inequities are created by a lack of control over behavioral choices or living
conditions or power structures. And so how do you change the map of health in America?
( 09:11 ):

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Power has to change hands, and right now the American healthcare system is one of the most
entrenched power structures in the world. So how do you transfer power from within the healthcare
system to the people in the communities that we are serving. That is the inspiration for IMPaCT. And the
answer to that question permeates every layer of this. Number one, it's about the workforce. You have
to hire people from within those communities and lift them up so that they're not just serving the health
system agenda, that they're really able to set the agenda alongside the people that they're serving. So
yes.

Margaret Flinter ( 09:51 ):
One of the most important contributions I think you and your team have been making is to show
durational impact over time. We get so excited, often very good research, but it's in a period of time.
And then one wonders is it sustained? But I think you've shown those sustained impacts over time, and
one area is around the cost savings, which we only hope that those cost savings get reinvested in the
community. But I believe the research just for our listeners shows $2,500 annually per patient for every
$1 returning almost $2.50 cents in savings. Dropping hospitalizations very significantly, which is one of
the most challenging things to do over time and increasing satisfaction with primary care.
( 10:43 ):
So tell us about this in terms of duration over time. In and of itself, the IMPaCT model, having these or
other factors coming into play, just your perspective as the leader of this over so many years to get
these kinds of returns on investment to make the reinvestments and what's next? How do we continue
to build on that?

Dr. Shreya Kangovi ( 11:07 ):
All fantastic questions. What is the secret sauce to having an effective intervention and then having the
effects persist? We don't know. In some cases we know that it works, but the understanding of why it
works, these mechanisms are really complex. I think that in part, again, it's because community health
workers are asking people what they want and think they need to do in order not just to improve a
single target outcome. Sometimes we get so siloed in healthcare that we think, "Make sure we have to
get this person their mammogram, we have to get this person their vaccine." But when you take a step
back and you say, "Margaret, what do you want in order to improve your life and your health?"
( 11:57 ):
Then you can really think about some deep structural changes. And when you're able to accomplish that
with somebody as their community health worker, you are much more likely to see a lasting effect that
persists beyond the immediate intervention period even so. If I'm your community health worker and
we work on some things together and then I say, "Hey, okay, goodbye, good luck." The effects continue
to persist, which is really remarkable and I think it's because there's some deep underlying change there.

Mark Masselli ( 12:31 ):
I want to pull the thread on Margaret's question about value and really talk a little bit about the dollars
and the sense. The sense we've got from you already about the value of this program, and you've been
leading a lot of growth. The US Department of Veterans Affairs, many state Medicaid programs, 18
states have used their IMPaCT model to create their own community health worker. Walk through, for
people who are excited about this, but just trying to understand do other people get this who are
payers.
( 13:02 ):

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And how are they reacting? And do you see any exemplars out there as you look at the Medicaid
agency, which is so important to those in serving the larger broader safety net community to have them
come on board? Tell us about some of your experiences.

Dr. Shreya Kangovi ( 13:20 ):
Absolutely. Fantastic question. You can have an amazing program, but without the right enabling policy
environment, it's hard to spread. And so what I am really excited about and I think why this is really the
moment for community health workers is that there is really starting to be enabling policies. Number
one, CMS, Medicare just introduced the first ever billing code for community health worker services,
and that was introduced just today really in the new physician fee schedule. Those services are modeled
after evidence-based IMPaCT services, and we really believe that that is going to set the tone for all
payers as Medicare often does. So that is a real bright spot in the policy landscape.
( 14:11 ):
Number two, there are real exemplars in the Medicaid space. One agency that I want to call out as
TennCare, which is the state medicaid agency of Tennessee. They are really out front in terms of
considering not only how do we think about sustainable financing for community health workers, but
how do we make sure that when money comes, these programs are built right. That we are really
investing in the infrastructure that community health workers will need in order to be successful. Again,
that goes back to things like, number one, making sure that you're hiring the right people who come
from within the communities in the first place.
( 14:53 ):
And not just checking a box saying, "Oh, somebody took a training program, but they happen to be
some other job from the suburbs and they just took a training program." That doesn't make you a
community health worker. So hiring the right people, investing in their ongoing professional
development, providing the right workflows and technology. They are really, I think, out front in that
regard. And then the third right spot is that there are efforts to really create some, what we call integrity
guardrails around this workforce. What I mean by that is when funding comes and I think it will come,
billable codes or value-based payment is really starting to surface for reimbursing and covering the
workforce.
( 15:40 ):
How do you make sure that it doesn't corrode the workforce? Again, how can you guard against all sorts
of different people who aren't community health workers checking a box and billing for that service
description while they're doing some sort of a telephonic checkbox case management. URAC, which is a
national accreditation agency, is creating standards that will ensure that the quality of the services are
maintained and using sort of evidence informed best practices and will also protect the integrity of the
workforce itself. So I think those are policy factors that are really making me feel bullish about not only
the spread of the workforce, but the spread of best practices to support the workforce.

Margaret Flinter ( 16:30 ):
I know in the 18 states that have replicated the model, you must be including not just urban areas like
Philadelphia, but some probably quite rural or even sparsely populated areas. And I was thinking as you
spoke, the overriding principle to really listen to what people want and need, and yet I think funders are
probably also very focused on. And what are the big issues and outcomes that we're seeing certainly in
the rural areas today, the maternity deserts and the increasingly negative outcomes of pregnancy,
certainly the deaths of despair, addiction.

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( 17:13 ):
How does IMPaCT tailor the training to help people, whether it's rural or urban, understand those issues
that have some of the specific knowledge necessary to be of help to people? Tell us a little bit about
that.

Dr. Shreya Kangovi ( 17:29 ):
Great question. I think the key is that it's not just the training, it starts again with the hiring. So think
about a rural community in Appalachia. You are going to want to recruit individuals from within that
very community to be community health workers. I'll tell you a story. There's a community health
worker named Brie Burke who lives in Tennessee. She grew up in a small community outside of one of
the urban centers in Tennessee, and her father was a preacher. Her mom was studying to become a
nurse, and she grew up knowing what it meant to not have ends meet all the time, and yet her family
always gave back.
( 18:14 ):
She talks about where there were days where her mom would cry because she didn't have enough food
to feed the kids, but they would still pile in a car and give to others and visit people at their bedsides and
share what little they had with others. That is someone who is going to grow up and be a community
health worker as she did. As an adult, she said, "I was shocked to find out that there is a job where I can
just help my community because that's what I've always done." And then she meets a patient, Serene,
and I'm telling the story with permission. And this is a woman who has battled addiction and in the
process of her addiction, had lost her two children, her two young boys, and that's devastating for any
mother.
( 18:59 ):
At the time where she met Brie, she had become clean and had been clean for a couple of months but
was still homeless. Now, Brie became everything for her, her confidant, her champion, her community
health worker. First things first, she had a whole list of medical conditions, but Serene didn't care about
anything else except getting her boys back. And so that is what Brie focused on. Again, focus on what
people have top of their mind. You can't lecture somebody about their A1C when they're worried about
their kids. So she helped deal with all of the custody issues, get visitation set up, get all of her drug
testing.
( 19:36 ):
She helped her to find a place to rent, and within two weeks she was moving into a house because she
had helped her find a job. She looked into a community group in her town that supplied her with
furniture and toys for the kids, and before long she had regained custody of her children. So that's a
story to illustrate this approach works in every different kind of setting that you can imagine because it
is by its very nature tailored not only to the community but to the individual.

Mark Masselli ( 20:10 ):
I love that so much. You're really talking about getting down to the roots of where people are and how
they're going to grow up and grow into it, and the pathway that we need to make. And I want to talk a
little bit about, you've talked about your roots, about your Indian heritage and what you saw when you
visited India, how that country and others, including Native Americans have relied on community health
workers for a long time. This is not a flash in the pan hundreds of years ago.
( 20:42 ):

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So I'm wondering why there's a disconnect that people haven't connected back to the roots of this
particular model, and what are you doing to try to educate people so they can be grounded?

Dr. Shreya Kangovi ( 20:56 ):
Great question. Community health workers are not a new workforce. They're a 300-year-old workforce,
and one of the most important things for us to be able to do is learn from that 300 years of history.
There has been a lot of work that's been done to advance the workforce and really importantly, to learn
what are the success factors. Over that 300 years, some community health worker programs were highly
effective and others were not. What distinguished those successful community health worker programs
really goes back to those same pillars, those core components of effectiveness. When we first started
out 15 years ago, beyond doing what we called the porch tours, which was talking to 1500 patients.
( 21:43 ):
We also read every single paper that has come out of those 300 years of history to learn what made
some programs really succeed. And that's how we got to, "Okay, well, it's these factors you have to hire.
You have to do the right training. You have to have such and such workflows." That's really what
America at this critical juncture has the advantage of building upon because we can learn from all of our
sister community health worker programs in other countries. Why haven't we done this yet? Well, we
didn't have a system that was designed for it. We had a perversely designed system that was a sick care
system and not something that was intended to generate health.

Margaret Flinter ( 22:24 ):
Well, you spoke about finding people with the right heart for this work, and obviously that is critical, but
even with the right heart and perhaps even more so with compassion and sensitivity, people encounter
very difficult situations. Not all situations have the outcome we all would hope for. Really curious if
you'd like to comment on what is necessary for support of the community health worker, not just the
training piece, but the support that helps people continue to do work, which really calls forth great
empathy, but also can be subject as with everybody in healthcare to burnout into a loss of that resiliency
that's so important.

Dr. Shreya Kangovi ( 23:07 ):
Oh my gosh, that is a fantastic question and probably the most important point that I can make in this
conversation is that it is not just about training. There is such a misconception in the community health
worker field, but in workforce in general, that it's all about training. But as you pointed out, there's so
much more infrastructure that we need to provide to ensure that community health workers feel
supported and are able to actually execute on the important work that they do. So for example, in the
IMPaCT model, we've created workflows that really guide community health workers through all sorts of
different situations that they might find themselves in.
( 23:51 ):
These aren't checklists. They do leave room for autonomy and flexibility, but you are not out on your
own trying to understand, "Well, what do I do if Mrs. Jones has a gun, or what do I do if somebody's
boyfriend is upstairs and trying to hurt them?" These are very common situations that community
health workers find themselves in, and there's a myriad more that have to do with community health
worker safety and wellbeing. So number one, working off of an evidence informed model that provides
these sorts of workflows is really critical. This is not something you can DIY or try this at home because

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then you won't have those supports where community health workers will know what to do in these
tricky situations.
( 24:37 ):
The other piece is supervision. It's so critical to have supportive supervision. We know this from World
Health Organization implementation studies of global programs, as well as our work in the United
States. And in the IMPaCT model, for example, we don't just train community health workers, we train
the supervisors because you can train somebody until their blue in the face, but if their boss doesn't
understand their job or know how to support them, they're not going to get very far.
( 25:02 ):
And a lot of that supervision training and support is around burnout prevention and creating spaces for
community health workers to share with their peers so that they can have that outlet for some of that
real secondary trauma that they're going to experience in this role.

Mark Masselli ( 25:20 ):
I really like the sort of thought that you really need to produce evidence informed research. And you
may know we run the Weitzman Institute, so it's near and dear to our heart about implementation,
improvement, science, and you've held focus groups with community health workers and published a
research paper. And I'm wondering if you could tell our listeners a little bit about what did you ask of the
folks you were doing? What did you learn from the work?

Dr. Shreya Kangovi ( 25:50 ):
Well, it is probably not just one. Every time we do anything, it is through participatory action research.
And so all the way back 15 years ago when we first developed IMPaCT to, yes, today when we were
designing a feature of our application that community health workers use. There's always community
health workers in the room. I'll give you an example. We have technology now that allows community
health workers to really access all of those evidence-based workflows at their fingertips. It supports
documentation. It supports them in setting and tracking goals that patients have created for themselves.
( 26:31 ):
And we had community health workers in the room today when we were deciding about a particular
feature. And we learned from them that they really want to continue to make sure that the actions that
community health workers take are blessed by the patients that they're serving. In other words, they
didn't want to just have the community health worker do a screener for unmet social needs where
you're asking somebody, "So you have enough food to eat? Do you face any intimate partner violence?
( 27:05 ):
Here's a number to a food pantry, or here's a number to a shelter." That is not a transfer of power. What
they said that they continue to want is you can do some assessments, but then at the end of the day,
you have to ask the patient, what do you want to do with this information? What do you want to
accomplish? And that really informed the design of the technology. So I can't just give you one answer
because there's a thousand ways in which community health worker input has shaped IMPaCT.

Margaret Flinter ( 27:35 ):
I was thinking as you were speaking, that one always has to make the case for what they do, but you've
made this case for decades, and there is a long history before that, other programs. I was probably the
most familiar with Pathways out in Ohio, the late Dr. Reding who had decades of building a wonderful

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program. And one wonders why people always have to be asking for funding when you've demonstrated
the savings and the return into the community. I'm just curious if you could wave your wand.
( 28:09 ):
Would community health workers be a public utility the way we have public education? It's there. It's in
a community. It's to be used as needed. Do you see it as being more effective tied to the healthcare
system or the public healthcare system somehow, or freestanding organizations? Really curious, your
thoughts on that, maybe all the above, but what have you seen that perhaps is most sustainable and
enduring?

Dr. Shreya Kangovi ( 28:35 ):
Fantastic question, and it hearkens back to your questions about how is this in India and in other
countries? I think thinking about that community health workforce as a public utility is the right way to
go because truly this is a workforce that can address a whole range of issues in a cost-effective manner.
But I'm also a realist, and one of the principles of IMPaCT is design for dysfunction. We are not there yet,
and so we have a fragmented system. And in that regard, I don't think there is a wrong door for
community health workers.
( 29:16 ):
I think it's through public health, through community-based organizations, which is really the sector that
has employed community health workers in this country the most robustly over the past 100 years, and
then of course now through healthcare. So I think community health workers can really find their way to
IMPaCT through any of those doors.

Mark Masselli ( 29:38 ):
Really, a very enlightening conversation. We'll continue to follow your success and the success of the
community health workers, which you are partnered with. And I want to thank you for joining us, and
thanks to our audience for being here. Be sure to subscribe to our videos on YouTube, and as always,
you can go online to chcradio.com to sign up for emails, updates, and share your thoughts and
comments about this program. Thank you so much. We continue to follow your incredible work. Thank
you for your leadership.

Dr. Shreya Kangovi ( 30:08 ):
Thank you. A lovely time talking with you all. I appreciate it.

Margaret Flinter ( 30:15 ):
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
retransmitted in whole or in part without the express written consent from Community Health Center,
Inc. The views expressed by guests are their own, and they do not necessarily reflect the opinion of
Conversations on Healthcare or its affiliated entities.

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