Improving Outcomes | Creating Careers
Improving Outcomes, Creating Careers: A New Way Forward in the Bronx—and Beyond
The Bronx is a vibrant, diverse, and resilient community of 1.4 million people, a third of whom are Montefiore patients.
We know that many of them face complex and overlapping challenges that impact their health and well-being, and we are determined to face them together.
Community health workers (CHWs) have become vital changemakers. They help to reduce pervasive disparities in health outcomes and enhance the quality and cultural competence of care providers.
Through the Community Health Worker Institute (CHWI) and its affiliated Community Health Systems Lab, we have the unique opportunity to positively impact up to 460,000 of the nation’s most underserved people. We also have the opportunity to revolutionize the way community health workers are trained and employed.
Inclusive Care: CHWs Answer an Important Need in Patient Care
CHWs play a pivotal role in healthcare delivery, particularly for providers like Montefiore Medical Center that serve predominantly low-income, underserved communities. They are trusted professionals, whose close understanding of the populations they serve helps facilitate better access to services and improve the quality and cultural competence of the care that Montefiore provides.
By bridging the gap between the clinical setting and the lived experience of patients in the community, CHWs address critical social determinants of health (SDOH) and improve outcomes in the process.
Addressing Social Determinants of Health
SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect their health and well-being. For example, the availability of stable housing, access to transportation, and the proximity and affordability of nutritious food can all factor into overall health outcomes. A growing body of research shows that access to quality healthcare only accounts for about 20 percent of what influences patient health; at least 50 percent relates to patient behaviors, socioeconomic conditions, and other SDOH that are often challenging to address in clinical visits.
Since CHWs typically reside in the communities they serve—usually sharing ethnicity, language, socioeconomic status, and life experiences—they have the ability to bring information where patients need it most. They are vital, frontline agents of change because they can uniquely reach and relate to fellow community members.
33 400
Households assisted per CHW annually
Percentage of patients who report resolution of, or progress on, a social need
Unique patients screened for social needs in 2024
92 173,328 9,442 Active CHWs
Households assisted since June 2022
The Community Health Worker Institute embeds CHWs in Montefiore practices across the Bronx.
Bridging the Gap: The CHWI Builds on Decades of Experience
Montefiore has employed CHWs since 1970, but, until recently, never in a systematic capacity. Instead, small pilot programs have historically enabled program administrators to hire and train CHWs for the length of a given grant cycle. In order to provide the most effective care and optimize what CHWs could achieve, institutional leaders determined that both infrastructure and sustainability were critical to their success.
Kevin Fiori, MD, MPH, MS—Director, Social Determinants of Health in the Office of Community and Population Health at Montefiore; and Associate Professor,
Departments of Pediatrics and Family and Social Medicine at Albert Einstein College of Medicine—conceptualized the CHWI based on his experience in West Africa. In 2003, Dr. Fiori helped found Integrate Health, an organization whose mission was to achieve universal health coverage. His work in Togo with cohorts of CHWs informed a need for a similar system in the Bronx community.
Montefiore initially established the CHWI in 2021; today, it is an independent department, making it easier for the CHWs to work in any setting across the health system. Donor support has financed as many as 28 CHWs to help cover Montefiore’s primary-care network; obstetrics practices; HealthySteps program, which serves parents of infants and toddlers; and pediatric services at the Children’s Hospital at Montefiore.
Still, more are needed.
CHWs are focused on building longterm relationships with patients.
Their roles are threefold:
1
Accompaniment
Partner with patients to identify and overcome barriers to better outcomes, including those related to healthcare, as well any circumstances outside clinical walls.
2
Navigation
Help patients navigate nonhealth-related needs like food benefits, job training, and transportation.
3
Continuity
Follow up with patients to ensure their needs are being met and help to develop additional solutions.
A Launching Pad: Helping Careers in Healthcare Take Flight
We conceived the CHWI to be more than a service-delivery program; it is a sustained, long-term, professionaldevelopment system. More than 30 percent of Bronx residents live below the poverty line, and the unemployment rate is the highest in the state. We aim to take community members in the Bronx, many of whom face racism and structural impediments to economic development, and place them in a position to use the program as a springboard to a career in healthcare. The CHWI purposefully recruits people with skill sets and backgrounds that many healthcare employers may reject, including immigrants; people with general equivalency diplomas, or GEDs; those with non-violent criminal records; and both older and younger adults. And because the majority of CHWs come from other industries, we have the
opportunity to expand the overall healthcare workforce. Montefiore hires all CHWs as full-time employees and provides 2,000 hours of on-the-job training. Once they begin engaging with patients, CHWs also take classes during their workdays in partnership with Hostos Community College, and their field hours count toward an apprenticeship certification from the New York State Department of Labor (NYSDOL). Most Montefiore CHWs receive their apprenticeship certification in 12 to 15 months.
A certified CHW can then apply nine hours of credit toward an associate degree at Hostos or Orange County Community College (SUNY Orange), as well as pursue upward movement within Montefiore’s healthcare system or elsewhere. Of note: All current CHWI supervisors started out as CHWs. Many CHWs were also Montefiore patients, who, after receiving support from a CHW, were motivated to become one.
Professional Development Pathway
A month of intensive, paid training
Continuing professional development paired with field work and classroom instruction
CHW apprenticeship certification from NYSDOL; ongoing employment opportunities in healthcare
“ ”
The CHWI is a mechanism by which we can get community members into our health system and launch their careers so that they can become the next generation of leaders.
—Kevin
Fiori, MD, MPH, MS Director, Community Health Worker Institute
Measuring Success: A Focus on
Data-Driven Decision-making
To ensure that CHWs can maximally improve patient outcomes—and to effectively enumerate how CHW services save health systems money—data collection and analysis are paramount. The Community Health Systems Lab serves that purpose. Working in lockstep with the CHWI, the Lab collects and analyzes data to incrementally create improved, replicable models of care here and for healthcare providers at large.
Of particular importance are patient-reported outcome measures, or PROMs. Does a patient feel better? Has their housing or food-assistance problem improved? These assessments are a high priority for health systems like ours that are developing them to ensure patients and families are engaged as partners in their own care.
The key metric collected on the clinical side is missed appointments, because they are bad for everyone: missed opportunities for patients to connect with providers and a fixed financial loss for health systems. Thus far, research has shown that patients who are assisted by Montefiore CHWs miss fewer appointments in the primarycare setting.
Sustainment Strategy: The Future of the CHWI
We believe every person who enters the Montefiore Health System deserves access to our services. We also believe that in the future we can maintain that breadth of care almost exclusively through sustainable reimbursements, government funding, and institutional funds. Philanthropy has a role to play in both.
In the near term, private donors and extramural grants are essential to expand the program to 100 CHWs, which would be enough to serve 35,000 patients annually; scale the evidence that CHWs effectively improve patient health outcomes; and continue to innovate. As Medicaid, Medicare, and private insurers begin to cover the services CHWs provide, our own institutional funds will help cover the costs of recruiting, training, supervising, and supporting the CHWs themselves. Thanks in part to the CHWI’s advocacy, insurance reimbursements are already on the horizon.
Diverse funding streams will make it possible for us to continue developing and building upon this unique and necessary model of patient care; the determination and ingenuity of the people of the Bronx will continue to inspire us to do it. We hope you’ll join us.
—Damaris Flores, Montefiore Community Health Worker and apprenticeship certificate recipient “ ”
Every day I get to see firsthand the way this program has helped a family or individuals grow and get the supportive services that they need. It’s amazing to contribute to that.
Montefiore Einstein