NDLI: Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York

Content Provider	Springer Nature : BioMed Central
Author	Fiori, Kevin P. Levano, Samantha Haughton, Jessica Whiskey-LaLanne, Renee Telzak, Andrew Muleta, Hemen Vani, Kavita Chambers, Earle C. Racine, Andrew
Abstract	Background In recent years, health systems have expanded the focus on health equity to include health-related social needs (HRSNs) screening. Community health workers (CHWs) are positioned to address HRSNs by serving as linkages between health systems, social services, and the community. This study describes a health system’s 12-month experience integrating CHWs to navigate HRSNs among primary care patients in Bronx County, NY. Methods We organized process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains to evaluate a CHW intervention of the Community Health Worker Institute (CHWI). We used descriptive and inferential statistics to assess RE-AIM outcomes and socio-demographic characteristics of patients who self-reported at least 1 HRSN and were referred to and contacted by CHWs between October 2022 and September 2023. Results There were 4,420 patients who self-reported HRSNs in the standardized screening tool between October 2022 and September 2023. Of these patients, 1,245 were referred to a CHW who completed the first outreach attempt during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician or CHW without being screened and were referred to and contacted by a CHW. Of the 2,804 total patients referred, 1,939 (69.2%) were successfully contacted and consented to work with a CHW for HRSN navigation. Overall, 78.1% (n = 1,515) of patients reported receiving social services. Adoption of the CHW clinician champion varied by clinical team (median 22.2%; IQR 13.3–39.0%); however, there was no difference in referral rates between those with and without a clinician champion (p = 0.50). Implementation of CHW referrals via an electronic referral order appeared successful (73.2%) and timely (median 11 days; IQR 2–26 days) compared to standard CHWI practices. Median annual cost per household per CHW for the intervention was determined to be $184.02 (IQR $134.72 – $202.12). Conclusions We observed a significant proportion of patients reporting successful receipt of social services following engagement with an integrated CHW model. There are additional implementation factors that require further inquiry and research to understand barriers and enabling factors to integrate CHWs within clinical teams.
Related Links	https://bmcprimcare.biomedcentral.com/counter/pdf/10.1186/s12875-024-02376-7.pdf
Ending Page	12
Page Count	12
Starting Page	1
File Format	HTM / HTML
ISSN	27314553
DOI	10.1186/s12875-024-02376-7
Journal	BMC Primary Care
Issue Number	1
Volume Number	25
Language	English
Publisher	BioMed Central
Publisher Date	2024-04-27
Access Restriction	Open
Subject Keyword	General Practice Family Medicine Primary Care Medicine Health related social needs Community health workers Health equity Primary health care Social determinants of health Social care integration
Content Type	Text
Resource Type	Article
Subject	Family Practice
Journal Impact Factor	3.2/2023
5-Year Journal Impact Factor	3.3/2023

Sl.	Authority	Responsibilities	Communication Details
1	Ministry of Education (GoI), Department of Higher Education	Sanctioning Authority	https://www.education.gov.in/ict-initiatives
2	Indian Institute of Technology Kharagpur	Host Institute of the Project: The host institute of the project is responsible for providing infrastructure support and hosting the project	https://www.iitkgp.ac.in
3	National Digital Library of India Office, Indian Institute of Technology Kharagpur	The administrative and infrastructural headquarters of the project	Dr. B. Sutradhar bsutra@ndl.gov.in
4	Project PI / Joint PI	Principal Investigator and Joint Principal Investigators of the project	Dr. B. Sutradhar bsutra@ndl.gov.in Prof. Saswat Chakrabarti will be added soon
5	Website/Portal (Helpdesk)	Queries regarding NDLI and its services	support@ndl.gov.in
6	Contents and Copyright Issues	Queries related to content curation and copyright issues	content@ndl.gov.in
7	National Digital Library of India Club (NDLI Club)	Queries related to NDLI Club formation, support, user awareness program, seminar/symposium, collaboration, social media, promotion, and outreach	clubsupport@ndl.gov.in
8	Digital Preservation Centre (DPC)	Assistance with digitizing and archiving copyright-free printed books	dpc@ndl.gov.in
9	IDR Setup or Support	Queries related to establishment and support of Institutional Digital Repository (IDR) and IDR workshops	idr@ndl.gov.in

Burden of unmet health-related social needs in an academic adult primary care practice in San Francisco California

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework

Implementing and monitoring high-quality community health worker care in adult primary care at New York City Health + Hospitals

Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting

Opportunities of integrated care to improve equity for adults with complex needs: a qualitative study of case management in primary care

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation

COVID-19 and Changes in Reported Social Risk Factors at a Primary Care Practice in the South Bronx

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York

Similar Documents

Burden of unmet health-related social needs in an academic adult primary care practice in San Francisco California

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework

Implementing and monitoring high-quality community health worker care in adult primary care at New York City Health + Hospitals

Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting

Opportunities of integrated care to improve equity for adults with complex needs: a qualitative study of case management in primary care

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation

COVID-19 and Changes in Reported Social Risk Factors at a Primary Care Practice in the South Bronx

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York