The delivery of healthcare services, while important, represents only 20% of the factors which contribute to a person’s health, according to representatives of Montefiore Health System. They said, in contrast, social determinants of health (SDOH) i.e. conditions that people are born into, work, and live in, which impact health outcomes such as housing, transportation and education are widely recognized as having the most significant influence on a person’s health.

 

Despite their importance, according to Montefiore representatives, SDOH are understudied and resources to address them within the healthcare system are rare. However, they say that’s starting to change. Montefiore officials said their Community Health Worker Institute (CHWI), launched in 2021, is establishing a model to address SDOH within an academic health system. They said the CHWI embeds local experts, known as community health workers (CHWs), into clinical teams to fill the gaps between medical care and social services in The Bronx.

 

“By having a community health worker 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 Fiori, M.D., M.P.H., M.S., director of CHWI and a pediatrician and researcher at Montefiore Health System and Albert Einstein College of Medicine.

According to Montefiore representatives, the CHWs within Montefiore Health System, who they say reflect the background, language, and lived experience of The Bronx community they serve, are frontline public health workers who serve as trusted members of the community. They said in partnership with 1199, 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 to ensure they are well equipped to identify patients’ social needs, and work with them to secure necessary services. They said these partnerships also create a pipeline of employment opportunities.

 

“To walk in a person’s shoes and empathize about experiences is the secret sauce that is sometimes missing in U.S. healthcare,” said Fiori, who is also associate professor of family and social medicine and of pediatrics at Einstein. He added, “It is a genuineness that can’t be fabricated, and is something we need more of. Our CHWs enable people to open up so we can learn about challenges impeding their family’s health.”

 

Montefiore officials gave the example of a CHW potentially learning about mold in a patient’s home that may be exacerbating their child’s asthma. They said the CHW will alert the medical team to the underlying mold problem, but will also help the patient address their unsafe housing conditions.

 

They went on to say that the CHWs are placed in different locations throughout the hospital system based on the results of SDOH screenings, which they say also take place throughout the hospital system. To date, they said Montefiore has screened more than 190,789 individuals and have found that approximately 20% have at least one social need.

 

Montefiore representatives went on to say that they have also 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 the Children’s Hospital at Montefiore. They said the initial goal is to serve approximately 9,000 patients and families annually.

A unique aspect of the CHWI, according to Montefiore officials, is its Community Health Systems Lab, which conducts research on SDOH and the impact of CHWs. They said 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.

 

They said the goal is to use data to inform best practices, identify the most useful resources for patients, and determine the best interventions to ensure the CHWs are most effectively deployed. In addition, they said 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.

 

Renee Whiskey-LaLanne, M.P.H., MCHES, AE-C is associate director of CHWI and director of community partnerships in the department of family and social medicine at Montefiore and Einstein. “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,” she said.

 

Whiskey-LaLanne added, “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 [have] the potential to inform new standards of care for communities who have historically been socially and economically marginalized.”