Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York
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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.
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A study from our health system found CHWs effective in connecting over 78% of patients with social services and of those connected, over 93% reported their HRSN improved or fully resolved.
“A study from our health system found CHWs effective in connecting over 78% of patients with social services and of those patients connected, over 93% of patients reported that their HRSN had improved or fully resolved. 20”
From Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx (2025) · cites this paper as [20]
The Results > Effectiveness passage reports that 78.1% of 1,939 patients were either connected to social services or equipped to connect on their own; it does not say all 78.1% received services. The same passage reports that 93.3% of patients connected to a service said their HRSN improved or fully resolved. Page numbers were not provided in our copy. (LLM, conf=0.89)
Experimental — accuracy not yet measuredThere is still a significant proportion of patients who are not successfully connected with CHW services.
“While CHWs are effective in addressing the HRSNs of patients, there is still a significant proportion of patients who are not successfully connected with CHW services. 20”
From Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx (2025) · cites this paper as [20]
There is high variability in referral rates across clinical sites ranging from 6.4 to 72.4% of eligible patients referred to CHWs.
“There is high variability in referral rates across clinical sites ranging from 6.4 to 72.4% of eligible patients referred to CHWs. 20”
From Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx (2025) · cites this paper as [20]
Previous research within this health system found little difference in referral rates at sites with or without clinician champions, however engagement levels of clinical champions was not examined.
“Although many program staff and CHWs stated that a clinician champion is integral to a functioning team, previous research within this health system found little difference in referral rates at sites with or without clinician champions, however engagement levels of clinical champions was not examined. 20”
From Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx (2025) · cites this paper as [20]
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- Authors
- Fiori, K. P., Levano, S., Haughton, J., Whiskey-LaLanne, R., Telzak, A., Muleta, H., Vani, K., Chambers, E. C., & Racine, A.
- Affiliations
- Albert Einstein College of Medicine (US)
- Corresponding author
- Fiori, Kevin P.
- ORCID
- Venue
- BMC Primary Care
- Published
- 2024-04-27
- Volume
- 25
- Issue
- 1
- Pages
- 140-140
- ISSN
- 1471-2296 (ISSN-L)
- 2731-4553
- PMC
- PMC11055265
- OpenAlex
- W4395695303
- Cited by
- 22
- References
- 33
- Citations by year
- 2026: 9 · 2025: 13
- FWCI
- 12.92
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Family Practice (publishedVersion, cc-by)
- Research Square (acceptedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- New York Health Foundation
- Doris Duke Charitable Foundation (2023-0258)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Community Health and Development
- Health Sciences › Health Professions › General Health Professions › Public Health Policies and Education
- Keywords
- community health workers, health-related social needs, social care integration, health equity, primary care, social needs screening, social services referral, implementation evaluation, RE-AIM framework, social determinants of health
- MeSH terms
- Adult, Aged, Community Health Workers, Female, Humans, Male, Middle Aged, New York City, Primary Health Care, Social Work, Delivery of Health Care, Integrated
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