NUR 8200 Module 4 Social Needs Paper: Community Health Workers, Navigation Trials and Return on Investment Example

Two Dollars and Forty-Seven Cents: Building a Community Health Worker Program for Social Needs After Discharge in Camden

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8200: Integrating and Evaluating Population Health in Advanced Nursing Practice

Mentor Name

Month Day, Year

Two Dollars and Forty-Seven Cents: Building a Community Health Worker Program for Social Needs After Discharge in Camden

The Problem

The Camden hospital here is fictional, a 400-bed hospital whose patients are largely covered by Medicaid or uninsured. A social needs screen added to admission last year found that 41 percent of adult medical patients reported at least one unmet need, most often food, housing, transportation or utilities. Patients with needs were more likely to miss their first follow-up visit and to return to the hospital within 30 days. Social workers focus on the most complex discharges, and many patients leave with only a printed list of resources. The DNP-prepared vice president for population health was asked to design a program.

The screen used asks ten questions in English and Spanish about food, housing quality and stability, transportation, utilities, safety and ability to pay for medicines. Nurses ask the questions at admission and enter answers in structured fields, so the data can be counted. Of 4,200 adult medical admissions screened last year, 1,722 reported a need. Food and transportation were the most common, but housing instability was the need most strongly linked with returning to the hospital within 30 days.

What Community Health Workers Can Do

Kangovi et al. (2014) randomized 446 general medicine inpatients who were poor, uninsured or on Medicaid at two Philadelphia hospitals either to usual care or to IMPaCT, whose community health workers met patients during admission, created action plans around the patients' own goals and provided support for two weeks after discharge. Patients in the program were more likely to get primary care within 14 days, 60.0 percent compared with 47.9 percent, to report high-quality discharge communication, and to improve in mental health and patient activation. Physical health, satisfaction and medication adherence did not differ, and total 30-day readmissions were similar, though repeat readmissions were lower in the program group.

Kangovi et al. (2020) then analyzed return on investment using data from a randomized trial of IMPaCT rather than a before-and-after comparison, which can be misleading because patients with very high use tend to improve on their own. On their estimate, a Medicaid payer would recover $2.47 within twelve months for each dollar spent, largely through fewer hospital days.

The Value of In-Person Navigation

Gottlieb et al. (2016) tested social needs screening in pediatric primary and urgent care clinics at two safety-net hospitals in San Francisco. All 1,809 caregivers were screened; half received written information about community services and half received in-person navigation from a trained navigator, with follow-up. Four months later, the number of social needs fell more in the navigation group, and caregivers in that group reported greater improvement in their children's overall health. The trial showed that screening alone is not enough; help connecting families to services adds benefit.

Program Design

The program hires six community health workers from Camden neighborhoods, chosen for life experience and listening skills rather than degrees, and trains them using the published IMPaCT curriculum, which the program's developers make available. Each worker carries about 25 patients at a time. Eligibility is adult medical patients who are uninsured or on Medicaid and live in Camden County. Workers meet patients in the hospital, ask about their goals rather than starting from a checklist, and build a plan together. After discharge, workers accompany patients to their first primary care visit when needed, help apply for food assistance and utility relief, connect them to housing services and check in weekly for at least two weeks, longer for those with complex needs.

A nurse and a social worker share supervision, receive regular caseload review and are paid a living wage with benefits, since turnover would undermine relationships with patients.

A typical patient shows how the work unfolds. A 58-year-old man admitted for heart failure says his goal is to get back to his job as a school custodian. His worker learns that he ran out of his water pill because his car broke down and the pharmacy is two bus rides away. Before discharge, the worker arranges mail-order delivery, helps him apply for a transportation benefit through his Medicaid plan and books a clinic visit for the following Tuesday, then rides the bus with him to that visit.

Partnerships

The program depends on community partners. The paper proposes formal agreements with a food bank, a housing nonprofit, the county welfare office and a legal aid clinic, with referral pathways that confirm whether help was received rather than ending at a phone number. The hospital's existing relationships with the Camden Coalition and faith communities are used.

Fidelity and Measures

Because programs that drift from their design lose effect, the program tracks fidelity: the share of patients met before discharge, with a goal-based plan and with contact after discharge. Outcomes include the share with a primary care visit within 14 days, social needs resolved at 30 days, patient activation, 30-day readmissions and hospital days over six months. A comparison with eligible patients not served during the first year, while the program grows, provides a reference, though the paper notes this is weaker than a randomized trial.

Cost and Payment

The annual cost, mostly salaries for six workers and two part-time supervisors, is presented to the board alongside the return-on-investment finding. New Jersey's Medicaid program and its managed care plans are approached about paying for community health worker services, and the hospital's community benefit budget covers start-up.

Conclusion

Four in ten adult medical patients at this Camden hospital have unmet social needs that affect their recovery. A randomized trial showed that community health workers improve timely primary care and patient activation, a trial-based analysis showed a return of $2.47 per Medicaid dollar, and a navigation trial showed that in-person help outperforms printed lists. The program hires and trains workers from the community, builds partnerships that confirm help was received, tracks fidelity and outcomes and seeks payment from Medicaid plans.

References

Gottlieb, L. M., Hessler, D., Long, D., Laves, E., Burns, A. R., Amaya, A., Sweeney, P., Schudel, C., & Adler, N. E. (2016). Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatrics, 170(11), Article e162521. https://doi.org/10.1001/jamapediatrics.2016.2521

Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207-213. https://doi.org/10.1377/hlthaff.2019.00981

Kangovi, S., Mitra, N., Grande, D., White, M. L., McCollum, S., Sellman, J., Shannon, R. P., & Long, J. A. (2014). Patient-centered community health worker intervention to improve posthospital outcomes: A randomized clinical trial. JAMA Internal Medicine, 174(4), 535-543. https://doi.org/10.1001/jamainternmed.2013.14327