AJMC September 11, 2025
This study of community health workers as clinical extenders demonstrates significant cost savings in managing chronic conditions among Medicaid beneficiaries.
ABSTRACT
Effective chronic disease management must extend beyond clinical visits into the daily lives of patients, particularly in low-income communities with a disproportionate burden of illness. This study examines City Health Works’ intervention model, which deploys highly trained nonclinical health coaches as tightly integrated extensions of primary care teams to support patient self-management. In a 12-month evaluation of Medicaid patients with poorly controlled diabetes and hypertension at a NYC Health + Hospitals outpatient site, the intervention achieved significant reductions in health care costs compared with a matched comparison group. These findings suggest that a technology-enabled, community-based workforce model can cost-effectively improve chronic...
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