Community Health Worker Institute Is Training and Deploying a Workforce to Address Social Determinants of Health and Deliver Life-Changing Care Throughout the Region

Social determinants of health (SDOH)—conditions like housing, transportation and education into which people are born, work and live—account for about 80% of what influences health. Despite their importance, SDOH are understudied, and resources to address them within the healthcare system are rare. But that’s starting to change.

As part of its mission to ensure that Bronx patients and their families achieve the best possible health outcomes, Montefiore Einstein’s Community Health Worker Institute (CHWI) is establishing a model to address SDOH within an academic health system. The CHWI embeds local experts, known as community health workers (CHWs), into clinical teams to fill in the gaps between medical care and social services in the Bronx.

“By having community health workers as part of the clinical team, they can effectively get to the root of health problems and identify real-world solutions that can significantly improve the health and well-being of our patients,” said Kevin P. Fiori, MD, MPH, MSc, Executive Director, Community Health Worker Institute, Montefiore Einstein, Attending Physician, Division of Academic General Pediatrics, Children’s Hospital at Montefiore (CHAM), and Associate Professor, Pediatrics and Family and Social Medicine, Albert Einstein College of Medicine.

Building the Workforce

Reflecting the background, language and lived experience of the Bronx community they serve, the CHWs at Montefiore Einstein are frontline public health workers who serve as trusted members of the community. In partnership with 1199SEIU, the largest healthcare union in the nation, and Hostos Community College, one of only two New York State Department of Labor accrediting institutes for CHW education, CHWs receive rigorous training and ongoing education, so they are well equipped to identify patients’ social needs and work with them to secure the necessary services. These partnerships also create a pipeline of employment opportunities.

For example, a CHW may learn there is mold in a patient’s home that is exacerbating a child’s asthma. The CHW will alert the medical team to the underlying mold problem, but the CHW also helps the patient address unsafe housing conditions.

The CHWs are placed in different locations throughout Montefiore based on the results of SDOH screenings that take place throughout the system. To date, Montefiore has screened more than 190,789 individuals and found that approximately 20% have at least one social need. Montefiore has identified specific zip codes and services where there is greater need for CHWs, including primary care, pediatric and family medicine locations, OB-GYN clinics and the pediatric hematology/oncology unit at CHAM. The initial goal is to serve approximately 9,000 patients and families annually.

Ensuring Evidence-Based Care

A unique aspect of the CHWI is its Community Health Systems Lab, which conducts research on SDOH and the impact of CHWs.

The lab has created new ways to gather and analyze data on SDOH and health status and has developed novel workflows so that the impact of CHWs on the lives of Bronx residents can be evaluated. The goal is to use data to inform best practices, identify the most useful resources for patients and determine the best interventions to ensure that CHWs are deployed most effectively.

In addition, the lab will track medical costs to evaluate savings that can be attributed to CHWs, making the case for payers like commercial insurance, Medicare and Medicaid to invest more in this model of care.

“As a former CHW and health educator who worked in the Bronx for 13 years, I am acutely aware of the challenges our community faces,” said Renee Whiskey-LaLanne, MPH, MCHES, AE-C, Associate Director, Community Health Worker Institute, Montefiore Einstein, and Director, Community Partnerships, Community Health Systems Lab, Albert Einstein College of Medicine. “What is not always clear is the best step to support our patients and families. Because our CHWs collaborate across clinical departments, we can work effectively across the health system to observe trends in how families, not just individuals, are navigating social services. Looking at this fuller picture is unbelievably powerful. Our findings will not just help our Bronx population but also has the potential to inform new standards of care for communities who have historically been socially and economically marginalized.”

If you would like to be part of this work or have any questions, please contact the Community Health Worker Institute at 718-430-3667 or at renee.whiskey@einsteinmed.edu.