Evaluation of a Community Health Worker (CHW)-Led Comprehensive Neighborhood-Based Program for Medicaid Enrollees in Detroit

Evaluation of a Community Health Worker (CHW)-Led Program


Lead sponsor: University of Michigan

Collaborator: Molina Health Care of Michigan
Meridian Health Plan of Michigan
Blue Cross Complete
Detroit Department of Health
Blue Cross Blue Shield of Michigan Foundation
Ralph Wilson Foundation

Source University of Michigan
Brief Summary

The investigators are comparing health care utilization claims data of Medicaid beneficiaries who participated in a CHW program led by three Medicaid health plans' salaried CHWs in the Cody Rouge neighborhood of Detroit, Michigan with eligible beneficiaries who were not invited to participate in the program but received usual health plan services.

Detailed Description

This program evaluation examines the effectiveness, barriers and facilitators of implementing a geographically targeted program led by salaried CHWs from three Medicaid health plans in collaboration with the Detroit Health Department and Joy Southfield Community Development Corporation. Beneficiaries who reside in the Cody Rouge neighborhood and had more than 3 Emergency Department (ED) visits or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months are randomized to the CHW program or to usual outreach from the health plans. CHWs reach out to eligible beneficiaries to provide a comprehensive assessment of health, behavioral, and social needs; link them to needed resources; and provide necessary follow-up. At 12- month follow up, health plan claims data on ED visits, ambulatory care-sensitive hospitalizations, primary care visits and all related costs will be compared between participants who participated in this program compared with other participants who would have been eligible but were not offered the program (with no effort to contact them).

The investigators hypothesize that patients enrolled in the CHW intervention will experience a reduction in acute care usage resulting in cost savings compared to those receiving usual health plan CHW outreach. This study is among the first to evaluate the impact on health care utilization of augmented services delivered by health plan CHWs for high-utilizing health plan members. This study will provide important information on the sustainability of future health plan CHW programs and provide insights into effective implementation of such programs.

Overall Status Active, not recruiting
Start Date March 1, 2018
Completion Date October 1, 2020
Primary Completion Date October 1, 2020
Study Type Observational
Primary Outcome
Measure Time Frame
Emergency Department Visits 12-month period after participant enrolls in the program
Hospitalizations 12-month period after participant enrolls in the program
Primary care visits 12-month period after participant enrolls in the program
Enrollment 198

Intervention type: Behavioral

Intervention name: Supportive services

Description: Assessment of behavioral, medical, and social needs, development of individual goals and action plan, follow-up to assist and work to ensure identified needs/goals are met. CHWs use their professional judgement to assess how long follow-up is required.


Sampling method: Non-Probability Sample


Inclusion Criteria:

- Either have had more than 3 ED visits in the prior 12 months, or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months

Exclusion Criteria:

- None if they meet above criteria.

Gender: All

Minimum age: 18 Years

Maximum age: N/A

Healthy volunteers: No

facility University of Michigan
Location Countries

United States

Verification Date

April 2020

Responsible Party

Responsible party type: Principal Investigator

Investigator affiliation: University of Michigan

Investigator full name: Mary Ellen Michele Heisler

Investigator title: Professor

Has Expanded Access No
Arm Group

Arm group label: Community Health Worker

Description: initial comprehensive health, behavioral, and social needs assessment; development of an individualized 'action plan' to address identified needs; linkage to necessary services and work with neighborhood-based health care and social services organization to address each individual's unique needs; and 4) provide follow-up support as needed.

Arm group label: Usual Health Plan Services

Description: 1) receipt of other plan services besides the CHW program for which they are eligible.

Patient Data Yes
Study Design Info

Observational model: Case-Control

Time perspective: Prospective

Source: ClinicalTrials.gov