A Health Program with IMPaCT

When Randy Hastings, a senior community health worker at Penn Medicine, first went to meet Anthony Jones, he had some reservations. Looking over the last few years of his new client’s medical history, which included diabetes and heart problems, Hastings couldn’t help but wonder if Jones was ready to tackle the challenges ahead. Community health workers are partners with their clients, clearing the path of whatever obstacles are keeping them from better health and recovery. But, ultimately, the client must be willing to take the necessary steps.

“I have to admit, when I did his initial interview, and be­cause of the fact that he had a couple of medical issues, I wondered if this was something he could handle and follow through with,” Hastings said recently. “But Anthony was ready. He was motivated from the beginning and easy to work with.”

They met at the office of Jones’s primary-care doctor, where Jones and his physician had already discussed his weight-loss goals for the next six months. It was Hastings’s job, in the course of their initial 30-minute interview, to start outlining realistic steps toward achieving the goals.

“I basically explained to him how this works, that we break it into smaller steps, something that’s manageable and com­fortable for him,” Hastings said.

Jones was on board immediately. He decided that he would tackle the exercise part of the plan from home, walking in his neighborhood. With the brutal cold of the previous winter fi­nally receding, it was the perfect time to get outdoors. That decided, he then mentioned to Hastings that he needed help with the second part of the plan.

“Because of his diabetes, he wanted to meet with a nutrition­ist to get a menu plan and a shopping list,” Hastings recalled. “So I made him an appointment that day with a diabetes nutri­tionist at the Perelman Center. He kept his appointment and got a low-calorie menu plan. He did a follow-up or two with the same nutritionist and also started walking, as promised.”

The first meeting between community health worker Orson Brown and Patricia Quick didn’t go quite as smoothly. It was late in the day, and there were others with Quick at her pri­mary-care doctor’s office. There wasn’t going to be time for the traditional one-on-one introductory interview. Still, Brown politely and respectfully introduced himself to everyone there, and let Quick know he’d be helping her meet her health goals. Most important, despite the limits of the interaction, Brown immediately made some observations that would be critical to their partnership in the months ahead.

^{Orson Brown built a relationship with Patricia Quick on the basketball court.}

Hastings and Brown are part of the team at the Penn Center for Community Health Workers. The center uses the custom- made IMPaCT model adopted by the University of Pennsylvania Health System to provide individualized, home-based, and community-based care to high-risk patients. (IMPaCT stands for “individualized man­agement for patient-cen­tered targets.”) The pro­gram is based on re­search begun in 2010 by Shreya Kangovi, M.D., G.M.E. ’10, M.S. ’13, aimed at determining and overcoming the barriers to better health for low-income patients. An assistant professor of medicine, Kangovi is the founding director of the center.

By grounding their work in the experiences of patients themselves, the researchers learned that often the barriers are not necessarily medical — and are often beyond the ability of doctors to learn or fix in the course of an office visit. Sometimes the problems are as simple as being unable to get medication at a pharmacy or not having transportation to appointments. Housing and nutrition problems also can get in the way of maintaining good health. And it’s one thing for a health pro­fessional to urge more exercise, but for a patient, finding the motivation to take that first step can be daunting.

Enter the community health worker, a bridge to a wide range of medical and social needs for clients who lack the skills and resources to navigate what can appear to be daunting medical or human services systems. One on one, the commu­nity health workers help patients set realistic goals, provide critical links to specialists or city and state agencies, and offer guidance and support along the way. The aim, after their six-month partnership, is for patients to have the skills and self- efficacy they need to continue on their path to better health.

The concept isn’t new, but Penn Medicine’s approach is. In fact, the research included studying where similar programs had fallen short. As a result, community health workers are not out there on their own. They are on the ground working closely with patients but are in regular contact with supervi­sors and a team that offers expertise in both medical and so­cial work – the better to tackle any barrier to better health. And Penn has been careful about whom it hired for these cru­cial positions. When the center was established in 2013, it had six full-time employees. Today, there are 24 community health workers, each with 140 hours of college-accredited training. This year, with more than $2 million in federal and philan­thropic funding and support from Penn Medicine, they will provide navigation, social support, and advocacy for more than 1,500 high-risk patients. 

The ideal candidates for these positions – again, based on asking patients what would help them most – come from the community. They’re the people who are already looking out for their neighbors, checking in on the sick, providing rides where needed, and offering guidance and emotional support during tough times.

For example, Brown, who started with Penn Medicine last year, was already helping the sick and shut-ins as a member of Grace Christian Fellowship in Southwest Philadelphia. He and his wife don’t live in the city, but they wanted to worship where the need was greatest. When a Penn recruiter visited one Sunday, literally sitting right next to Brown before he was called on to address the congregation, it seemed like a sign. “For me, it was like breathing fresh air,” Brown said. “I had been looking for a career change, wanting something where I could make more of an impact on people’s lives, to help them. This sounded like the perfect fit.”

Hastings inherited his community spirit from his mother, a longtime fixture in South Philadelphia, where he was born and raised. Long before he began his work with Penn in 2013, he and his mother were there, helping others. “The work I’m doing now isn’t much different from what I’m used to,” he said. “It’s what I’ve always done for my neighbors and my fam­ily and my friends, connect them with resources, discuss medical problems, and help with private issues.”

Brown noticed two things in that all-too-brief meeting with Quick. First, how quiet she was. He would have to find some way to gain her trust, to get her to reveal more about herself. The second came from the way she shook his hand, even how she carried herself. He thought, she’s played ball somewhere. So when he followed up by phone the next day, a Friday, he asked. Turned out she hadn’t just played – she loved playing. She had been a three-sport athlete in high school. Well, Brown continued, since her goal was to lose weight and exercise more, would she meet him on a basketball court Monday?

“And she was right there with it,” he said.

Although she was game, she wasn’t strong. She hadn’t been on a court in years. So the plan was to play to five and see how that went. And while they played, finally, they had that initial interview.

“I used that time to just try to pry my way in a little bit as we’re playing,” Brown said. “Question here, question there, get a feel for who she is, what’s important to her, what she’s trying to work on.”

Gradually, the quiet woman he met the week before started to talk. And, in the process, she beat him.

“It was good because she felt good,” Brown said. “She enjoyed doing it, and I took pleasure in that, helping her do something she likes to do.”

The games became a weekly event. She didn’t always win. But they did always talk.

“We started to get a better understanding of each other,” Brown said.

Jones stuck to his goals, short and long term. He would walk at least three times a week in his neighborhood, first in South Philly and later near his new home at 56th and Market. He’d head out first thing in the morning, sometimes combin­ing the exercise with his day’s errands. Hastings joined him on one occasion.

“I just stopped by because I was in the neighborhood and wanted to see how he was doing,” Hastings said. “We walked and we talked, about three blocks. He really got out there and got that done.”

Jones’s pace is slow, but he is steady and determined. When alone, Hastings said, “he just puts the buds in his ears with his music and he just takes it all in stride. He’s a laid-back type of guy. He just doesn’t stress.”

In the first month with a new client, Hastings tries for at least three in-person visits, but he was also calling Jones al­most weekly to check on things like his blood sugar levels. 

“Anthony was easy to work with,” Hastings said. “I call and ask him about his numbers, and he would just get them. I’d ask if he wanted to participate in this or that, and he was always motivated to go.”

They went to doctors’ appointments together. They toured the YMCA on 52nd Street, to see if workouts there could sup­plement Jones’s walks. And they took the El into Center City to shop at the Reading Terminal Market. Hastings thought it a perfect location for a diet-conscious person to take in a wide array of fresh fruits and vegetables. Jones patiently and steadily walked the crowded aisles with Hastings, black straw hat atop his head. After much careful deliberation, he found what he was looking for: mountain trout. He likes it fried.

The games between Quick and Brown had gradually gotten longer. To ten points, then sixteen. By mid-August, they were ready to play to thirty-two, but you had to win by two bas­kets. They met on the courts of the Francis Myers Recreation Center, where a mural proclaims, “I have seen that if you truly desire something better, it’s not as hard as you think.” 

At this point in their partnership, Quick was no longer weak. She jumped out to an early lead, at one point dribbling in and making a layup, going ahead 6-2. She dribbled the ball between her legs, made an easy hook shot, dominating as the score hit 14-2. Even with Brown towering over her at one point, she ducked around and made another basket. Brown started to push harder, getting himself back in the game, while regularly checking to make sure she was doing OK. She was more than fine.

“All net,” she cried at one point, going further ahead to 26-10. Then another from the outside, and one more from near the foul line. A commanding 30-10 lead. One more to win.

And that’s when Brown started to come back. He had taken some good-natured teasing at the office after that first game – for losing to a girl – so even if he couldn’t always win, he would try to play respectably. But he also used the time to check in with Quick, to make sure she was doing all right – in between the moments spent trash-talking each other. On this day, by the time Brown tied the game at 30-30, Quick had slowed down.

“I get tired,” she said.

“You all right?” he asked more than once.

Indeed she was, making one more basket from the foul line and then ending the game with a layup.

They high-fived. “Way to compete,” Brown congratulated her. “Way to not give up, to keep on fighting.” 

The pair cooled down at a bench on the sidelines, but the work continued. Quick has been looking for a new home for her and her twin sister. The two abandoned houses on either side of her were attracting problems that created too many headaches for someone who was trying to stay on a healthier, stress-free track. So after the game, Brown set up his shop courtside. While she held the game ball, he had his phone out, a list of numbers in folder before him. He started making a se­ries of calls about potential new places for Quick to live. 

“She needs to get out of that place and into better housing, and she needs help with that,” he said later. He didn’t consider it a distraction to his work with her but an important part of his mission. “Whatever the obstacle is that’s keeping her from achieving a health goal – well, I’m here to help her through that.”

At one point, Jones had run out of his medications, some­thing Hastings only learned about during their weekly check-in. It wasn’t an emergency situation, Hastings said, but he immediately set up a three-way call with Jones and his primary-care doctor. The prescription was called in to the local pharmacy, Jones picked it up, and he then checked in with Hastings to let him know that all was well. 

Hastings says he’s learned that just leaving such issues to the clients to resolve can sometimes mean unnecessary de­lays. “When I make a three-way call, I know it’s done and off their plate,” he said. “It’s something I work hard to teach pa­tients: Do it now. I want it to become a new habit, something that will help them be self-sufficient.”

He wants his clients to be ready to fend for themselves after their six-month partnerships end. In some cases, he’ll even quiz his clients about what just happened. “OK, we just did this,” he’ll say. “Now, what did we accomplish here? And what did we learn? What would you do the next time?”

Not all of their encounters are quite so serious.

During one in-person visit early in the relationship, Jones seemed upset. His disability check hadn’t arrived, he told Hastings. He didn’t know how he was going to pay his bills. Hastings immediately shifted into advocate mode. “I started freaking out,” he said. “I said we were going to call this person and that person. I started to think that maybe it had just been mailed late, or might arrive later in the day.”

In the middle of the freak-out, Jones said, “April Fool!” and started laughing.

“When he did that,” Hastings said, “I knew the ice was broken for sure.”

For his part, Jones said he suspects that he and Hastings will stay in touch after their six-month collaboration ends. “He really gets where I’m coming from,” Jones said. “He cares.”

Quick had hoped to move by the end of August, but despite her efforts, and Brown’s, things weren’t working out as they’d hoped. Although frustrating, Brown says it’s important to re­member that there are limits to what people can do, even with the best of intentions. “There’s no way you can have all the answers when dealing with other people’s problems,” he said. “You have to be mindful that it can weigh you down, to carry the weight of the world on your shoulders. I’m going to work hard to find the answers, and I have good support – from supervisors and co-workers – to help me do that. But it’s tough when you’re going through that moment.”

Fortunately, Quick and Brown have a common bond that helps them through such times. “One thing that makes it easier with Patricia is that we both have a belief in and a foundation of prayer,” he said. “Many times, if I’m not sure how to figure something out, I’ll say, ‘Let’s pray about it.’ It’s a good thing that we can come together in common purpose and pray, and it’s been a great thing in the relationship I have with her.”