The Community Health Worker Institute (CHWI) strives to improve health equity by optimizing community health worker integration within clinical care teams. Community health workers are a bridge between social and clinical care and serve as an invaluable workforce for health systems. Using embedded implementation science, the CHWI aims to demonstrate the value and effectiveness of community health workers as an innovative workforce solution to address adverse social determinants of health, improve access to healthcare for disadvantaged populations, and serve as an entry point to sustainable healthcare careers for local community experts.
The CHWI is embedded within Montefiore’s ambulatory network where it serves as a resource for multiple clinical departments and service lines across Montefiore Health System. The CHWI optimizes the recruitment, training, deployment, continuing professional development and integration of community health workers (CHWs) while designing a cost-effective, value-based model to sustain them. The Institute has four primary objectives to achieve optimization of the CHW workforce at Montefiore and demonstrate a return on investment:
Standardization & Adoption
Standard scopes of practice, training curricula, and supervision
Management & Accountability
Integration of CHWs into care corrdination teams with access to promote social and health serive coordination.
administration and operations with MHS.
CHWs will be Montefiore employees
Outcomes oriented research using pragmatic clinical trial
designs and real-world evidence will generate data informed
improvement and cost effectiveness research more rapidly
Sustainment & Scale
Adapting best practices system-wide. Demonstrating cost
savings using return of investment analysis. Dissemination
of major findings and lessons learned internally and externally
Patient & Community Participation: Research questions and implementation guided by community members
with local expertise and shared lived experience.
CHWI implementation and research is supported by the Community Health Systems Lab based at Albert Einstein College of Medicine. The Community Health Systems Lab (CHSL) includes an interdisciplinary team of researchers, clinicians, and community partners that supports and enhances CHWI operations through technical assistance and data systems learning. CHSL is embedded within the CHWI as the monitoring, evaluation, and learning unit.
CHSL is led by Kevin Fiori, MD, MPH, MSc, FAAP, Director of Social Determinants of Health, Community & Population Health at Montefiore Health System and Associate Professor of Pediatrics and Family and Social Medicine. Dr. Fiori also serves as the executive director of the CHWI. Renee Whiskey-LaLanne, MPH, MCHES, AE-C, is Associate Director of the CHWI and leads community partnerships and participatory research.
In a county as diverse as the Bronx, effective community partnerships are the key to success. The CHWI works with a broad coalition of community- and faith-based social service providers, government agencies, healthcare providers, public schools, and community colleges to design and deliver social care to families that identify a need.
Patient-centered care that includes social support cannot be developed without patients and their families. For this reason, the CHWI’s Community Advisory Board includes a group of diverse patients at the center of its council, which also relies on membership from local social service providers, healthcare organizations, and academic institutions to drive our interventions and research agenda.
The Montefiore Community Health Workers Institute is supported by multiple foundations, internal funds, and private donations. However, we are committed to the design of value-based payment mechanisms that support transformational change at the system level to improve health equity and provide sustainable employment opportunities for families in the long term.
Since 2018, Einstein faculty involved in designing the system-wide social needs screening program and CHW referral architecture have published presentations, peer-reviewed articles, and research reports sharing results and lessons learned.
- Heller CG, Rehm CD, Parsons AH, Chambers EC, Hollingsworth NH, Fiori KP. The association between social needs and chronic conditions in a large, urban primary care population. Prev Med. 2021 Dec;153:106752. doi: 10.1016/j.ypmed.2021.106752. Epub 2021 Aug 1. PubMed PMID: 34348133; PubMed Central PMCID: PMC8595547.
- Garg A, Brochier A, Messmer E, Fiori KP. Clinical Approaches to Reducing Material Hardship Due to Poverty: Social Risks/Needs Identification and Interventions. Acad Pediatr. 2021 Nov-Dec;21(8S):S154-S160. doi: 10.1016/j.acap.2021.02.007. Review. PubMed PMID: 34740423.
- Fiori KP, Heller CG, Flattau A, Harris-Hollingsworth NR, Parsons A, Rinke ML, Chambers E, Hodgson S, Chodon T, Racine AD. Scaling-up social needs screening in practice: a retrospective, cross-sectional analysis of data from electronic health records from Bronx county, New York, USA. BMJ Open. 2021 Sep 29;11(9):e053633. doi: 10.1136/bmjopen-2021-053633. PubMed PMID: 34588265; PubMed Central PMCID: PMC8483051.
- Sanderson D, Braganza S, Philips K, Chodon T, Whiskey R, Bernard P, Rich A, Fiori K. Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211023883. doi: 10.1177/21501327211023883. PubMed PMID: 34109884; PubMed Central PMCID: PMC8202298.
- Fiori KP, Heller CG, Rehm CD, Parsons A, Flattau A, Braganza S, Lue K, Lauria M, Racine A. Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019. Am J Public Health. 2020 Jul;110(S2):S242-S250. doi: 10.2105/AJPH.2020.305717. PubMed PMID: 32663075; PubMed Central PMCID: PMC7362703.
- Fiori KP, Rehm CD, Sanderson D, Braganza S, Parsons A, Chodon T, Whiskey R, Bernard P, Rinke ML. Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program. Clin Pediatr (Phila). 2020 Jun;59(6):547-556. doi: 10.1177/0009922820908589. Epub 2020 Mar 5. PubMed PMID: 32131620; PubMed Central PMCID: PMC7357198.
- Heller CG, Parsons AS, Chambers EC, Fiori KP, Rehm CD. Social Risks Among Primary Care Patients in a Large Urban Health System. Am J Prev Med. 2020 Apr;58(4):514-525. doi: 10.1016/j.amepre.2019.11.011. PubMed PMID: 32199514; PubMed Central PMCID: PMC7362999.
- Fiori K, Patel M, Sanderson D, Parsons A, Hodgson S, Scholnick J, Bathory E, White-Davis T, Wigod N, Chodon T, Rich A, Braganza S. From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center. J Prim Care Community Health. 2019 Jan-Dec;10:2150132719899207. doi: 10.1177/2150132719899207. PubMed PMID: 31894711; PubMed Central PMCID: PMC6940600.
If you would like to be part of this work, or if you have any questions, please contact us.
Community Health Worker Institute
Albert Einstein College of Medicine
1300 Morris Park Ave
Bronx, New York, 10461