Evaluation of Community Health Worker Support to Improve Tobacco Use Disorder Outcomes in Medicaid Beneficiaries with Serious Mental Illness

About This Grant

PROJECT SUMMARY Tobacco use disorder (TUD) remains highly prevalent in people with serious mental illnesses (SMI), driving a significant mortality disparity in this population. First-line pharmacotherapies for TUD combined with behavioral support significantly increase tobacco abstinence rates in adults with SMI, yet are underutilized. Community health workers (CHWs) are lay health workers trained to provide health information and services, with a strong evidence base for improving uptake of health services in underserved communities. We showed CHW support from TTS trained lay staff with provider education on TUD treatment doubled tobacco abstinence rates in those with SMI through tripling TUD treatment uptake and impacting social determinants of health. Here we seek to test the effectiveness of CHW support, delivered by existing, trained, Medicaid-funded community behavioral health staff, for smoking cessation in adults with a SMI served by a Medicaid accountable care organization (ACO). Medicaid is the single largest payor of mental health services in the US. CHW deployment within Medicaid funded care structures to date has been generally limited to special waiver programs. Widespread adoption of Medicaid ACOs provides an opportunity to test whether existing behavioral care team members, with brief training, can function as CHWs, and whether such an innovation improves TUD, cardiovascular, and mental health outcomes. To do so, 937 adults with SMI and TUD, receiving behavioral healthcare through Medicaid ACOs in a large human services agency, will be enrolled and randomly assigned to receive behavioral health team support from their Intensive Case Manager (ICM) who has received brief CHW and TTS training or continue to receive usual ICM support (Enhanced usual care, EUC). All care team clinicians will be offered education on first-line, evidence-based TUD treatment in SMI. Our aim is to determine whether CHW support integrated into behavioral health care improves tobacco abstinence and cardiovascular risk in those with SMI and TUD when delivered by ICM staff within existing Medicaid ACOs, with the hypothesis that those assigned to Integrated CHW support will have higher rates of biochemically verified 7-day point prevalence combusted tobacco abstinence at 2 years than those assigned to EUC, the primary outcome, greater reduction in cardiovascular risk estimates at 2 years, greater improvement in psychiatric symptom severity, stress, and loneliness over two years, greater engagement with care, healthcare satisfaction ratings, and reduction in emergency department visits and inpatient hospitalization days in year 2 of the intervention than those assigned to EUC. Implementation of the Integrated CHW support intervention into existing Medicaid ACO behavioral care teams will be evaluated using quantitative data and qualitative stakeholder interviews. If effective, this intervention has the potential to be widely disseminated in existing, Medicaid funded systems of care and to be transformative in overcoming adverse SDoH to improve delivery of first-line, evidence-based medical care, reducing the enormous mortality disparity faced by people with SMI.