New York-Presbyterian Hospital developed two models for community health workers (CHWs) who assist at-risk patients in the community and help frequent ED visitors connect with primary care.

  • The program started with a pilot project to help the parents of pediatric asthma patients control the asthma. The project was so successful, the health system expanded the number of conditions and created partnerships with 14 community organizations.
  • CHWs in the community program meet with patients and families, assess their social needs, help them set goals, and meet with the primary care team and attend rounds at the hospital when patients are hospitalized.
  • CHWs called patient navigators cover five hospital EDs and help frequent utilizers connect with a primary care provider, set appointments, and follow up with patients until they go to an appointment.

To bridge the gap between at-risk patients and the providers treating them, New York-Presbyterian Hospital has developed two different models in which trained lay members of the community work with at-risk patients to help them navigate the healthcare system and manage their health.

Community health workers (CHWs) provide support to help patients in the community overcome any obstacles that interfere with receiving care or managing their conditions. They are employed by New York-Presbyterian’s community partners and are co-supervised by community partners and health system personnel.

In the second model, CHWs, called patient navigators, are employed by the hospital to work with frequent ED visitors and patients without a primary care provider. (For details on the patient navigator program, see related article in this issue.)

“We see community health workers as being at the heart of healthcare. They speak the languages of the patient populations we serve, and understand the dynamics of the communities and the people who live there,” says Patricia Peretz, MPH, lead for the Center for Community Health Navigation at New York-Presbyterian Hospital.

The program began in 2005 with a grant to provide community support for the parents of pediatric asthma patients and help them keep their children’s disease under control. “It gave us the opportunity to work with local community-based organizations to develop a program design that encompasses the clinical aspects and social determinants of children with asthma,” Peretz says.

The pilot program for asthma patients served an area where 43% of children live below the poverty line, Peretz says. The population of the community was 75% Latino, and 51% of residents were foreign-born. Most of the residents spoke Spanish in their homes.

ED visits and hospitalizations decreased by more than 65% among children whose parents completed the year-long program. Nearly 100% of parents who completed the program said they felt they could control their child’s asthma.

The CHWs in the pilot program were bilingual and based in the community. They visited the patients in their homes and conducted an environmental assessment to identify any asthma triggers such as animal dander, house dust, or cigarette smoke, and worked with the families to eliminate the triggers.

CHWs also identified barriers to adherence to the child’s treatment plan and provided peer support to parents who were trying to manage their children’s asthma and cope with everyday stresses. They helped families sign up for assistance with housing and utilities, food, childcare, and other needs. They made sure the young patients were connected to a primary care provider, and reinforced the education family members received in the hospital and empowered them to understand asthma management.

They were part of the patients’ primary care team and met with the providers regularly, collaborating on interventions to meet the patients’ needs.

“The idea behind providing support in the community is that even the best-intentioned caregivers will have a difficult time managing their children’s illnesses if they are about to be evicted or there’s no food in the house,” Peretz says.

The pilot project was so successful that the health system administration agreed to fund and expand the program.

“Our outcomes demonstrated that community health workers based in community organizations can help patients and caregivers overcome the obstacles to following their treatment plan and staying out of the emergency department and the hospital,” says Adriana Matiz, MD, associate professor of pediatrics at Columbia University Medical Center and medical director for the Center for Community Health Navigation at New York-Presbyterian. “Using the data, we developed a business plan to continue funding the pediatric asthma project and to develop programs to support new populations.”

The organization expanded the program to include adult-onset diabetes and multiple geographic areas, including primary care medical homes where the CHWs are part of the healthcare team. Currently, the health system partners with 14 community-based organizations across the city and has adapted the model to provide support for patients with HIV, behavioral health issues, and multiple chronic illnesses.

Patients are referred to the program by members of the hospital treatment team or primary care providers, Peretz says. Patients eligible for the program may have a specific condition, financial or other social needs, or they may be adults with multiple chronic illnesses who are at risk for readmission.

For instance, a case manager in the hospital might identify a patient who is at high risk for readmission, ask the physician for a referral, and bring in the community health worker to assist in discharge planning and follow the patient after discharge.

“In my practice, I may be treating a child with complex medical issues and barriers that impede the care. Then, I engage the community health worker who is on my team to meet with the family and help them overcome the barriers,” Matiz adds.

Orders for a community health worker intervention go to the supervisory office where the case is assigned to the CHW, who then reviews information from the referring physician and uses it to plan the meeting and to support the patient in setting goals.

“The order for a community health worker clearly describes what I want to focus on so the community health worker is informed about the patients’ issues when they call to set up an appointment,” Matiz says.

The initial meeting with the families may be in the home, a school, the community-based organization, or another location where the patients feel comfortable.

When they meet a family for the first time, the CHWs conduct a comprehensive interview that includes assessing social needs, self-management abilities, and other challenges. They work with the family to develop and meet goals that complement the medical team’s goals. They help families navigate the healthcare system and access care in the appropriate setting. CHWs may accompany them to medical visits, and help them understand their medication regime and overcome barriers to care.

“The community health workers spend a lot of time with the family, getting to know them and building trust and identifying all of their social challenges. These may include housing needs, immigration issues, lack of food, or domestic violence. They find out what the family needs and connects them with resources,” Peretz says.

The CHWs meet regularly with the multidisciplinary team in primary care practices and report on the patient and family, their living situation, and psychosocial needs. “It’s an eye-opening experience for the medical team when the community health workers make their reports and we learn what is going on in the home,” Matiz says.

While patients are in the hospital, the CHWs attend rounds, assist in providing culturally appropriate education, and collaborate with the care team on transition planning. When patients are readmitted, they help the case management team determine the nonmedical causes, such as financial problems or lack of transportation.

“We are developing true partnerships to provide better care for our patients. Our community health workers are based within community organizations, which helps them remain anchored in the community while they have a strong presence in the hospital and patient-centered medical homes,” Peretz says.