A Multi-center Trial of IMPaCT CHW Support for Chronically-ill Patients

"The IMPaCT intervention has three stages:~1. Goal-setting: CHWs will help patients to deconstruct the chronic disease management goal they set with their PCP into patient-driven short-term goals and action plans.~2. Tailored Support: CHWs will conduct weekly follow-up for 6 months through either telephone or home visit in order to support the achievement of patients' short-term goals.~3. Connection with longitudinal support: IMPaCT CHWs will also facilitate a weekly patient support group."