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

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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.

Original languageEnglish (US)
Article number140
JournalBMC Primary Care
Issue number1
StatePublished - Dec 2024


  • Community health workers
  • Health equity
  • Health related social needs
  • Primary health care
  • Social care integration
  • Social determinants of health

ASJC Scopus subject areas

  • Family Practice


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