2024-2026

Filling the Gaps Between Medical and Social Needs

©Montefiore Einstein

2024-2026

Community Health Worker Institute

The Community Health Worker Institute (CHWI) was launched by Montefiore’s ambulatory care network in 2021. The Institute strives to improve health equity by integrating community health workers in clinical care teams, filling the gaps between medical care and social services in the Bronx. We’re funding the Institute’s efforts to demonstrate the value and effectiveness of this approach at addressing adverse social determinants of health, improving disadvantaged populations’ access to healthcare and providing an entry point to sustainable healthcare careers for local community experts.

www.cham.org

CHALLENGE

Healthcare services account for just 20% of the factors that contribute to a person’s health; the other 80% is influenced by social determinants of health - conditions like housing, transportation and education into which people are born, work and live. South Bronx - the poorest urban congressional district in the United States - has some of the country’s highest rates of diabetes, heart disease, asthma, HIV/AIDS and maternal and infant mortality. Lack of access to healthcare is just part of the problem. Despite their importance, social determinants of health are understudied and resources to address them within the healthcare system are rare.

©Montefiore Einstein

ACTION

Community health workers (CHWs) are a bridge between social and clinical care and thus constitute an invaluable workforce for health systems. They are also one of the few evidence-based interventions that address social risk factors.

The CHWI recruits, trains and deploys community residents as CHWs so they are well equipped to understand and identify patients’ social needs and work with them to secure the services they need.

For example, a CHW may learn there is mould in a patient’s home that is aggravating a child’s asthma. The CHW will alert the medical team to the underlying mould problem, but will at the same time help the patient address their unsafe housing conditions.

The CHWI also runs the Community Health Systems Lab, which conducts research on the social determinants of health and the impact of CHWs. The goal is to use data to inform best practices, identify the most useful resources for patients and determine the best interventions for ensuring that CHWs are deployed most effectively.

IMPACT

The initial goal is to serve approximately 9,000 patients and families every year and to recruit, train and deploy 100 CHWs by 2027.

9,000

PATIENTS AND FAMILIES

to be served every year

100

COMMUNITY HEALTH WORKERS

to be recruited, trained and deployed by 2027