Identifying Key factors for Targeting Patients most suitable for Community Health Worker program

  • Wang Q
  • Nandyala P
  • Chawla R
  • et al.
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OBJECTIVES: Community Health Worker (CHW) can help improve outcomes for community members by linking patients to community resources and helping patients avoid unnecessary hospitalizations. This study aimed to identify key factors that can differentiate patients that are most suitable for CHW program and prospectively identify such candidates from a privately insured health plan participants. METHODS: All Commercial and Medicare members eligible for CHW program and who were identified with one of the chronic diseases (CHF, COPD, CAD and diabetes) were examined. Correlation analyses and statistical tests were conducted between target variable (whether member engaged in CHW program) and all other demographic, socio-economic, clinical and consumer data to identify important variables. A similarity algorithm was developed to prospectively identify any members whose attributes are most similar/close to the attributes of already engaged members. RESULTS: Based on limited historical data, 56 out of 1955 eligible chronic members are suitable candidates for CHW program. The key factors found to be associated with their CHW enrollment status include age, household income, number of persons living in the household, concurrent and prospective risk scores, pharmacy costs, presence of type2 diabetes or hypertension, use of ambulance service in the past 12 months, likelihood of hospitalization score, length of time with various chronic diseases. The similarity algorithm included calculating distance between each enrolled CHW member and all the rest of eligible chronic members to identify candidates who are most similar to these existing members enrolled in the CHW program. As a result of the analysis, 7209 members were found to be most suitable candidates for CHW's outreach. CONCLUSIONS: By identifying important factors and targeting individuals who are most suitable for the program, Community Health Workers can address member's needs properly by filling the gap between communities and healthcare providers.




Wang, Q. C., Nandyala, P., Chawla, R., & Nigam, S. (2015). Identifying Key factors for Targeting Patients most suitable for Community Health Worker program. Value in Health, 18(3), A272.

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