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

PEER REVIEWED

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.

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