With more than 250 Community Health Workers, NYC Health + Hospitals has built one of the largest health system-based community health worker programs in the country
In a testimonial, cancer patient Neville Facey describes how a community health worker helped him with appointments, transportation, and financial assistance
NEW YORK, NY – NYC Health + Hospitals today announced that over 25,000 patients have worked closely with Community Health Workers since the program’s launch in 2021. Community Health Workers meet regularly with patients to identify and address barriers to health and well-being, such as housing, financial, food, and legal needs, as well as helping them schedule health care appointments and coordinate transportation. With more than 250 Community Health Workers, NYC Health + Hospitals has built one of the largest health system-based Community Health Worker programs in the country. In a testimonial, patient Neville Facey describes how a Community Health Worker helped him with appointments, transportation, and financial assistance. Community Health Workers are part of the primary care team at all of NYC Health + Hospitals’ 11 hospitals, 6 of its Gotham Health sites, and Virtual ExpressCare and they often come from the communities they serve. They can meet patients in the clinic, in the community, or at home depending on the patient’s preference. The program is open to patients regardless of immigration or insurance status. NYC Health + Hospitals’ Community Health Worker Program was launched in September 2021 as part of the NYC Public Health Corps, which also includes the NYC Health Department’s Neighborhood Health Corps.
The health system’s Arts in Medicine department has worked with The Museum of Modern Art (MoMA) to highlight the important work of supporting community health workers. Last night, the museum hosted a panel featuring the artist LaToya Ruby Frazier and health system staff to discuss the role of community health workers and premiered a new short film video by Pete Ho featuring community health workers. Earlier this year, Frazier gave health system staff a guided tour of her exhibition, Monuments of Solidarity, which features an artwork that celebrates and uplifts the stories of community health workers in Baltimore during the COVID-19 pandemic.
“CHWs have become an integral part of the way we deliver care at NYC Health + Hospitals. They are an incredible resource to our patients that allows us to treat our patients holistically, addressing both their medical and social needs in a patient-centered way. It has been an honor to work with MoMA and LaToya Ruby Frazier to bring the work of CHWs to the forefront,” said NYC Health + Hospitals Chief Population Health Officer Dr. Nichola Davis.
“Arts in Medicine is honored to collaborate with MoMA on this important event highlighting our Community Health Workers. This is significant because it builds a connection between two significant NYC institutions – MoMA and NYC Health + Hospitals – each one treasured as integral to our city, but which often feel like they belong to very different worlds. Artists like LaToya Ruby Frazier use their activism and voice to illuminate the work of essential workers and in doing so to advancing their role in health care paradigms,” said Larissa W. Trinder, Assistant Vice President of NYC Health + Hospitals Arts in Medicine.
NYC Health + Hospitals Community Health Workers serve adult patients, families with young children, adult and pediatric patients with Asthma/COPD, and adult patients with special needs, such as experiencing homelessness, involvement in the criminal-legal system, and behavioral health conditions.
- Adult primary care program: Community Health Workers are part of the primary care team at all of NYC Health + Hospitals’ 11 hospitals and 6 of its Gotham Health sites. Since program inception, over 7,000 patients have graduated from the 3-month adult primary care Community Health Worker program. Community Health Workers primarily help patients with food insecurity, financial insecurity, medical bills or gaps in health insurance, transportation, housing insecurity, social supports, and legal needs. Nearly all of the patients in the program have one or more chronic diseases. The most common diagnoses of patients in the program are hypertension, diabetes, heart disease, cancer, asthma, chronic kidney disease, and chronic obstructive pulmonary disease. A subset of Community Health Workers specifically support patients participating in the Lifestyle Medicine Program. Patients in this program work with a team to make evidence-based lifestyle changes including eating a healthful plant-based diet, increasing physical activity, improving sleep, reducing stress, avoiding substance use, and strengthening social connections. A new study, “Implementing and Monitoring Quality Community Health Worker Care in Adult Primary Care at New York City Health + Hospitals” was published in BMC Primary Care. The paper describes the launch of this large-scale program during its first two years.
- Pediatric program: Community Health Workers are part of the pediatric clinics at all of NYC Health + Hospitals 11 hospitals and 5 of its Gotham Health sites. Pediatric Community Health Workers work to support the health and wellbeing of young children up to age 5 and their families. Since program inception, 12,301 patients have graduated from the three- to six-month program. The three most common referral needs among families are early care and education, parenting support, and social needs, such as food, housing, benefits, and health insurance.
- Asthma/COPD program: Asthma/COPD CHWs work with adult and pediatric patients with uncontrolled asthma and COPD. The goal of the program is to reduce avoidable asthma/COPD emergency department visits and inpatient hospitalizations, improve patients’ ability to manage their asthma/COPD and connect patients to primary/specialty care. Since program inception, over 100 patients have graduated from the Asthma/COPD CHW program. The Asthma/COPD CHWs have specialized training in Asthma/COPD including the ability to coordinate with pest management services as appropriate.
- Behavioral Health program: Behavioral Health Community Health Workers serve adult patients with mental health diagnoses, substance use disorders, or both, across all 11 hospitals, 4 Gotham Health sites, and Virtual ExpressCare. Since program inception, over 6,600 patients have completed work with Behavioral Health Community Health Workers. One quarter of these encounters focused on aftercare follow-up and access to care services and three quarters are dedicated to connecting patients to specific concrete services, such as housing assistance, connection to services for benefits, education or employment services, legal and immigration needs, as well as accessing the Supplemental Nutritional Assistance Program (SNAP) and food pantries.
Special populations program: Community Health Workers typically spend over a year working with patients in an interdisciplinary team with two clinic models. The Primary Care Safety Net (PCSN) Practices serve people experiencing homelessness with complex care needs and the Point of Re-entry and Transition (PORT) Practices serve individuals returning to the community from incarceration. In the past year, over 500 patients have been enrolled in this program. Community Health Workers in this program address the specific complex medical, social, and behavioral health needs of clients both in clinic and through a street medicine program called SHOW.
