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An Emerging Model for Community Health Worker–Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia


The CHW-Based CCM model consists of 3 vertical boxes on the left-hand side, depicting referrals from health care providers of their high-risk patients. Arrows point to a box in the center that represents the care management team. This team is represented by a mid-level provider, a nurse, and community health workers. Below this box is a list of the functions of the care management team. These are: risk assessment, patient enrollment, develop a care plan, conduct weekly case reviews, and follow up with the primary care provider. Arrows from this box point to 3 vertical boxes on the left that depict interventions done in the community. The box on the top has community health worker assistance with ancillary and social services. The box in the middle has weekly community health worker home visits. The box on the bottom has involvement of patients in community events such as diabetes self-management education, diabetes self-management programs, gardening, and walking.

Figure 1.

Organizational structure of the chronic care management team, implementation of community health worker–based chronic care management, rural Appalachia, United States, 2017–2019. Abbreviations: CHWs, community health workers; DMSE, diabetes self-management education; DMSP, diabetes self-management program; NP, nurse practitioner; PA, physician assistant; PCP, primary care provider.

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Figure 2.

Enrollment in a community health worker–based chronic care management program, rural Appalachia, United States, 2017–2019.

Enrollment in a community health worker–based chronic care management program, rural Appalachia, United States, 2017–2019.
Month and Year No. of patients
May 2017 4
June 2017 18
July 2017 22
August 2017 26
September 2017 30
October 2017 38
November 2017 40
December 2017 53
January 2018 67
February 2018 79
March 2018 94
April 2018 124
May 2018 140
June 2018 165
July 2018 177
August 2018 204
September 2018 221
October 2018 295
November 2018 331
December 2018 357
January 2019 404
February 2019 444
March 2019 485
April 2019 529
May 2019 567
June 2019 617
July 2019 651
August 2019 690
September 2019 729

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