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.