Advancing Social Care Integration in Health Systems with Community Health Workers: an Implementation Evaluation based in Bronx, New York

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Fiori, Samantha Levano, Jessica Haughton, Renee Whiskey, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3943675/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Apr, 2024 Read the published version in BMC Primary Care → Version 1 posted 9 You are reading this latest preprint version 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 care provider 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 integrating CHWs within clinical teams. health related social needs community health workers health equity primary health care social determinants of health social care integration Figures Figure 1 Background Addressing the ways in which social needs influence health outcomes is critical to improving the health, well-being, and quality of life of communities and individuals. Health-related social needs (HRSN) represent the self-reported individual experiences of social risk factors at a particular moment in time (1). These HRSNs are distinct from the broader, structural social determinants of health (SDoH), which are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (2). In recent years, health systems have expanded their focus from access and quality of health care to include screening for and addressing HRSNs, which can influence more than 50% of a patient’s health (3). Increasing clinical teams’ awareness of HRSNs is an important first step in addressing health disparities, as outlined by the National Academies of Sciences, Engineering, and Medicine (NASEM) (1). Health systems have primarily integrated awareness activities by screening patients for HSRNs such as housing stability, food security, or transportation access (4). There remain clear gaps in how to best provide assistance once patients report HRSNs (5). Health systems have demonstrated variability in linking patients with HRSNs to appropriate resources and social service providers, also known as “social prescribing” (6). These decisions have recently shifted from the health system to regulatory agencies, which have identified HRSN screening and referral as an emerging priority. The Centers for Medicare & Medicaid Services (CMS) released new health equity measures, which mandate reporting and screening of key SDoH domains in inpatient settings in 2024 (7). Meanwhile, the Joint Commission now requires health systems to screen patients for HRSNs as well as to address the HRSNs identified through a defined action plan (8). Social prescribing activities may include referrals to onsite resources or community-based organizations, and involve nurses, social workers, student volunteers, or community health workers (6). Community health workers (CHWs) are frontline public health workers with deep understanding of, and trust within local communities (9). CHWs often serve as intermediaries between health care provider institutions, social services, and the community because they are uniquely positioned to facilitate access to resources, improve cultural competence of care delivery, strengthen patient self-sufficiency, and support communities in addressing the underlying causes of health disparities (10). There is evidence supporting the effectiveness of CHW interventions in the US in improving patient care, reducing cost of care, and advancing health equity (11); however, few studies have evaluated the impact of CHWs on HRSNs in real world practice. Previous randomized control trials (RCTs) examining CHW social prescribing interventions have reported reduced hospitalizations (12), improved health-related quality of life (13), improved access to primary care after hospitalization (14), and improved child health status (15) when compared to usual care. Additional CHW interventions have focused evaluations on the resolution of social needs (15) and connection to essential social services (16, 17, 18). There is a demonstrated gap in understanding how a large health system can successfully integrate an enterprise wide CHW program into clinical practice. This study’s objective was to describe and evaluate a health system’s 12-month experience integrating CHWs within clinical teams to address HRSNs among primary care patients in a large, multi-cultural, resource-constrained system in Bronx County, NY. Methods Intervention The Community Health Worker Institute (CHWI) at Montefiore Medical Center strives to improve health equity by optimizing the integration of CHWs within clinical care teams using a learning health system approach (19). CHWs serve as a bridge between social and clinical care by addressing HRSNs and improving access to healthcare for disadvantaged populations. The CHWI centralizes recruitment, training, continuing professional development, and deployment of CHWs embedded within the health system. Montefiore Medical Center primarily serves patients from Bronx County, New York, which is home to more than 1.3 million people (20). It is one of the most diverse counties in the US, with 56.6% of its residents identifying as Hispanic and 44.3% as non-Hispanic Black. Bronx County consistently ranks among the least healthy counties in New York State in measures of health factors and health outcomes (3). In spite of these challenges, the Bronx also has many assets and resources including access to higher education, healthcare facilities, open spaces, and community- and faith-based organizations (21). The CHWI builds on an initial pilot, the Community Linkage to Care (CLC) program, which modeled standardized HRSN screening and referral support in our health system in 2017 (22). As part of the CLC program, the health system implemented a 10-item HRSN screening tool adapted from the Health Leads Toolkit (Supplemental Fig. 1) (23). Clinicians reviewed the results of the screen with patients who self-reported at least one HRSN, and then asked the patient and their family members whether they were interested in receiving assistance with their HRSNs. If assistance was requested, clinicians would send an electronic referral order within the health system’s electronic health record (EHR) to facilitate connection to CHWs. If assistance was requested but a CHW was not available, clinical teams would utilize the health system’s EHR-supported social service directory to find available resources to refer patients to in their local community. Supplemental Fig. 1. Health-Related Social Needs Screening Tool, December 2019 – October 2023 In 2022, the health system centralized CHW operations within the CHWI structure, representing a novel and enhanced investment towards CHW integration within the health system. In prior work, we have demonstrated the successful reach and adoption of the HRSN screening arm of the CLC program (24). This study aims to evaluate the centralized CHW referral component of the program. Study Design & Data Sources This retrospective, cross-sectional study utilized data collected and managed through Research Electronic Data Capture (REDCap) tools to assess the integration of CHWs across the health system. REDCap is a secure, web-based software platform hosted at Albert Einstein College of Medicine, which is designed to support data capture for research studies (25, 26). The CHWI REDCap database is a tool designed for CHWs to routinely collect data on patient demographics, referral information, outreach encounters, social need services provided, and key program outcomes. This database was internally developed and has been continually updated by the CHWI team as part of our learning health system approach. Since the launch of CHWI, we have added new services offered in the community, integrated REDCap data access groups for CHW training, automated data entry processes for follow-up encounters, linked family members through unique record numbers, and streamlined reports to track patients with ongoing follow-up needed. Additional data was extracted from the EHR to identify patients eligible to be referred to CHWs through HRSN screening and electronic referral order databases. All EHR data was extracted using Microsoft SQL Server, version 18, to query data from the Epic Electronic Health Record Data Warehouse. Study Population Patients were eligible for inclusion in the analysis if they were referred to a CHW for HRSN service navigation and support within participating clinical teams and the first outreach was attempted by a CHW between October 2022 and September 2023. This time period reflects when the CHWI deployed its first cohort of CHWs within the system. Patients were initially referred to a CHW if they met the following eligibility criteria: 1) self-reported HRSNs by a standardized screening tool and requested assistance from a clinician, 2) self-reported HRSNs during the clinician visit and requested assistance from a clinician without being screened, or 3) self-reported HRSNs and requested assistance directly from the CHW, if on-site, without being screened. If the patient requested assistance directly from the CHW, the CHW would meet with the patient, contact the patient’s primary clinician, and request that the clinician retroactively submit an electronic referral order. We focused on an initial 12-month period to account for seasonality with additional follow-up outreach and outcomes for the patient after September 2023 being excluded from the analysis. Study Measures We organized both process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains (Table 1 ) (27). This framework facilitated and organized assessments of implementation with the study period. We utilized data from five ambulatory pediatric and five ambulatory internal medicine clinical teams that were actively participating in this initiative during the study period. All process and outcome measures were focused on these ten clinical teams. Table 1 RE-AIM Community Health Worker Institute (CHWI) Program Components, Measures, and Key Data Sources Components Measures Key Data Sources Reach R1: % of eligible patients screened positive for HRSNs who were referred to a CHW R2: total number of eligible patients referred to a CHW • EHR HRSN Screening Database • CHWI REDCap Database Effectiveness E1. % of eligible patients connected to at least one social service E2. % of eligible patients who self-reported resolution of progress on at least on HRSN • CHWI REDCap Database Adoption A1. % of eligible patients screened positive for HRSNs who were referred to a CHW by clinical team A2. % of clinical teams with a clinical champion present during the study period • EHR HRSN Screening Database • CHWI REDCap Database • Clinician Champion Tracking Sheet Implementation I1. % of referrals received via electronic referral order entered into CHWI database I2. median time, in days, between the electronic referral order date and first CHW contact date • EHR Electronic Referral Order Database • CHWI REDCap Database Maintenance M1. median monthly cost per household per CHW • Health System Operations Budget Reach We defined reach as the 1) proportion of patients with self-reported HRSNs in the screening tool who were referred to and contacted by a CHW (i.e., eligibility criteria 1 only) and 2) the total number of patients who self-reported HRSNs by any means and were referred to and contacted by a CHW (i.e., eligibility criteria 1, 2, and 3). Patients were eligible to be referred to a CHW if they self-reported HRSNs with or without a screener; therefore, the second reach measure estimates the absolute coverage of the CHWI program. We utilized the first reach measure to estimate the potential drop-off between initial self-report of HRSNs and first attempted contact by the CHW because the screening tool provides the only standardized documentation of patients with self-reported HRSNs who may decline assistance from a CHW prior to the clinician electronic referral order. To determine the proportion of patients eligible to be referred and contacted, we matched patients with self-reported HRSNs in the screening tool from the clinical teams of interest between October 2022 and September 2023 with patients contacted by CHWs from those clinical teams during the same time period using unique identifiers. For the second reach measure, we calculated the total number of patients contacted by CHWs from these clinical teams during the study period, since not all patients referred may have been screened using the standardized tool. For the total patients referred and contacted, we further described their referral status based on their stage in the initial contact and consent process. We reported socio-demographic covariates, including age at referral, gender, race/ethnicity, and preferred spoken language, which were collected and documented by CHWs in the CHWI REDCap Database. Effectiveness We defined our primary effectiveness measure as the proportion of patients assisted with HRSNs for which the CHW completed all necessary steps, per program workflows, to connect the patient to at least one social service. We also defined a secondary effectiveness measure as the proportion of patients reporting connection to at least one social service who resolved or made progress on at least one HRSN. This secondary measure was self-reported by the patient and only answered after both the CHW and the patient completed all the necessary steps to be connected to at least one social service. These measures were based on internally standardized definitions for all social needs and services (Supplemental Table 1). Adoption Adoption of the intervention was measured according to two measures, 1) the proportion patients with self-reported HRSNs in the screening tool who were referred to and contacted by a CHW by each clinical team and 2) the proportion of clinical teams establishing a clinician champion as recommended by the intervention. Clinician champions were defined as “full-time clinicians based at practice who serve as a clinical contact, mentor, and/or coach to support CHW team integration and lead performance improvement initiatives,” and have been previously demonstrated to increase screening rates in our health system (22, 28). We used two sample T-tests to estimate whether the proportion of patients referred and contacted differed for clinical teams with and without clinician champions present. Implementation Implementation measures included fidelity measures of the extent to which clinical teams and CHWs adhered to recommended, established workflows. These measures included 1) the proportion of patients with electronic referral orders who were referred to and contacted by a CHW, and 2) the median time, in days, between the clinician’s electronic referral order and the first CHW outreach attempt. It was an operational expectation by the CHWI for CHWs to contact patients within 7 days of the electronic referral order by a clinician. The CHWI also encouraged clinicians to complete a warm handoff, or transfer of care, with the CHW after the on-site clinical visit as part of their standardized workflow. Due to potential delays in the documentation of the electronic referral orders in the EHR, we confirmed the utilization of a warm handoff in the CHWI REDCap Database and assigned the time between the order date and first outreach as 0 days for these cases. We excluded all other observations when the first CHW outreach attempt was dated prior to the electronic referral order date. We did not assess time between the HRSN screen and electronic referral order since this is dependent solely on the clinician placing an order. To determine the proportion of patients with electronic referral orders contacted, we matched the EHR electronic referral order and CHWI REDCap databases using unique identifiers. Maintenance Maintenance was defined as the cost to sustain the CHWI intervention over time given the need to establish an estimated ongoing annual cost per beneficiary. This was measured by estimating the median annual cost to the health system per patient referred to a CHW. We first determined the annual patient count for each CHW and annual cost per CHW based on standardized CHWI salary estimates and time contributed by each CHW during the annualized study period. We then calculated the annual cost to the health system per patient for each CHW by dividing the annual patient count by the annual cost per CHW. Next, we calculated the weighted median annual cost to the health system per patient across the study period, with weights based on the proportion of months that the CHW participated in the intervention. We excluded observations for CHWs if they contributed partial data due to mid-month deployment or departure, provided only supplemental coverage to the clinical teams of interest, or demonstrated abnormal data due to performance concerns. Analysis We used both descriptive and inferential statistics to summarize socio-demographic characteristics of patients referred and RE-AIM process and outcome measures. All descriptive and inferential statistics were conducted in SAS version 9.4. Weighted estimates for the Maintenance measure were calculated using PROC MEANS in SAS. All research was approved by the Albert Einstein College of Medicine Institutional Review Board (2017–8434). Results Reach Between October 2022 and September 2023, 25,996 unique patients were screened for HRSNs within the ten participating clinical teams using the screening tool, with 4,420 (17.0%) reporting at least one unmet HRSN. Of the patients who self-reported HRSNs in the screening tool, 1,245 were successfully referred to and contacted by (i.e., completed the first outreach attempt) CHWs integrated within these clinical teams during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician (i.e., eligibility criteria 2) or CHW (i.e., eligibility criteria 3) and were referred to CHWs who attempted the first outreach. We summarized the socio-demographic characteristics of the total referred population (n = 2,804) (Table 2 ). Most patients referred were between 0 and 5 years of age (27.7%) followed by those between 30 and 64 years (23.9%). There were more women (55.7%) than men referred (43.8%). Referred patients most identified as Hispanic (42.4%) or Non-Hispanic Black (28.2%), with many patients declining to report their race or ethnicity (22.0%). Most patients preferred English as their primary language (74.3%) followed by Spanish (21.6%). There were 2,993 total HRSNs reported with the most reported HRSNs identified as housing security (24.7%), food security, (20.3%) and financial benefits (16.9%), respectively (Table 3 ). Table 2 Descriptive Characteristics of Patients with Self-Reported Health-Related Social Needs Referred to Community Health Worker Institute, October 2022- September 2023 Measures Number of Patients Referred (n, %) Total Patients 2,804 (100.0%) Age, in years 0–5 777 (27.7%) 6–11 487 (17.4%) 12–19 333 (11.9%) 20–24 71 (2.5%) 25–29 69 (2.5%) 30–64 670 (23.9%) 65+ 397 (14.2%) Gender Man 1,227 (43.8%) Woman 1,562 (55.7%) Transgender Man 1 (0.0%) Transgender Woman 3 (0.1%) Gender Non-Conforming 1 (0.0%) Other Gender 1 (0.0%) Declined to Report 8 (0.3%) Missing 1 (0.0%) Race and Ethnicity Non-Hispanic White 59 (2.1%) Hispanic 1189 (42.4%) Non-Hispanic Black 792 (28.2%) Non-Hispanic Asian / Pacific Islander 40 (1.4%) Non-Hispanic American Indian / Alaskan Native 11 (0.4%) Other 56 (2.0%) Declined to Report 618 (22.0%) Missing 39 (1.4%) Preferred Spoken Language English 2,084 (74.3%) Spanish 605 (21.6%) Bilingual, Spanish or English 31 (1.1%) Other Language 78 (2.8%) Missing 6 (0.2%) Table 3 Self-Reported Health-Related Social Needs (HRSNs) of Patients Referred to the Community Health Worker Institute, October 2022- September 2023 Measures Total HRSNs Identified (n, %) Total HRSNs 2,993 (100.0%) Housing Security 739 (24.7%) Housing Quality 313 (10.5%) Employment 98 (3.3%) Financial Benefits 505 (16.9%) Food Security 607 (20.3%) Care Coordination & Navigation 176 (5.9%) Referral to Health Homes Program 0 (0.0%) Legal Services 168 (5.6%) Youth & Family Services 312 (10.4%) Referral to Primary Care Provider 7 (0.2%) Other Need 68 (2.3%) There were 2,804 total patients referred from these clinical teams with the first outreach attempt completed by CHWs between October 2022 and September 2023. These patients were referred to a total of 28 CHWs, who each contributed a median of 3.0 months (IQR 2.0–6.5 months) during the 12-month study period. Of the patients referred with attempted contacted, 1,939 (69.2%) were successfully contacted and consented to work with a CHW to address self-reported HRSNs. An additional 124 (4.4%) patients were successfully contacted but have yet to consent to CHW assistance, 329 (11.7%) were successfully contacted but declined CHW assistance, 336 (12.0%) were disconnected after three or more unsuccessful initial outreach attempts, and 76 (2.7%) patients were still awaiting successful initial contact by a CHW (i.e., have not three or more initial outreach attempts) at the time of data analysis (Fig. 1 ). Effectiveness We measured CHW effectiveness through patient reported connection to social services. Overall, 1,515 (78.1%) of the 1,939 patients assisted received social services. Meanwhile, 13 (0.7%) patients failed to connect to services or were lost to follow-up before services could be confirmed. The remaining 411 (21.2%) patients are still actively working with a CHW at the time of study end period (Fig. 1 ). Of the patients who were connected to a social service, 779 (93.3%) reported that their HRSN was improved or fully resolved. Approximately 56 (6.7%) patients reported that they failed to make progress on their HRSN or were not able to document progress because they were disconnected from care. Adoption In our health system, every clinical team approached during the study period integrated CHWs into their team for HSRN navigation. Of the ten clinical teams, adoption of the referral component of the intervention varied with a range of 6.4–72.4% of eligible patients referred to a CHW, with a median referral rate of 27.8% (IQR 14.9–44.6%) (Table 4 ). We also measured adoption of a key aspect of the intervention, the adoption of a clinician champion within the team. Approximately 80% (n = 8) of clinical teams had recruited or retained a clinician champion during the study period to collaborate with the CHWI program team, educate other clinicians on the referral process, and discuss barriers and facilitators to implementation. There was no difference in the average rate of referral usage between clinical teams with (80%) and without (20%) a clinician champion present (p = 0.50). Table 4 Adoption of the Community Health Worker Institute Referral Program by Participating Clinical Teams, October 2022- September 2023 Clinical Team Clinician Champion Present Number of Patients with Self-Reported HRSNs in Screening Tool Number of Patients Referred to and Contacted by CHW Percent of Patients Referred to and Contacted by CHWs Clinical Team 1 Yes 188 7 3.7% Clinical Team 2 No 285 30 10.5% Clinical Team 3 Yes 195 26 13.3% Clinical Team 4 Yes 753 104 13.8% Clinical Team 5 Yes 581 115 19.8% Clinical Team 6 No 102 25 24.5% Clinical Team 7 Yes 844 240 28.4% Clinical Team 8 Yes 528 206 39.0% Clinical Team 9 Yes 596 253 42.4% Clinical Team 10 Yes 348 239 68.7% TOTAL 80% 4,420 1,245 Median 22.2% (IQR 13.3–39.0%) Implementation There were 3,316 patients with electronic referral orders sent by clinicians, after self-reporting HRSNs in the screening tool or directly to a clinician or CHW, between October 2022 and September 2023. CHWs completed the first outreach attempt for 2,427 (73.2%) of these patients, who are included in our study sample, with the remaining 889 patients (26.8%) still awaiting initial outreach by a CHW at the time of data analysis. There were 377 patients, of the total 2,804 referred patients in the study sample, who were excluded in this assessment because their electronic referral orders were sent outside of the study period. We measured the time between the patient’s electronic referral order and first outreach attempt by the CHW to better understand implementation of the intervention by CHWs. The median time for CHWs to first contact the patient was 11 days (IQR 2–26 days) after the electronic referral order, compared to standard CHWI expectation of 7 days. There were 273 patients whose electronic referral order and first outreach attempt were reassigned to the same day because their clinicians completed a warm handoff with the CHW, as confirmed in the CHWI REDCap Database. There were 392 patients with electronic referral orders sent after the CHW’s first outreach attempt that were excluded from this study. Maintenance There were 12 CHWs included in our assessment of median annual cost to the health system per patient to sustain the CHWI intervention. After applying analytic weights, calculated based on the number of months contributed by each CHW to the intervention, we determined that the median annual cost per patient was $ 184.02 (IQR $ 134.72 – $ 202.12). Discussion The CHWI reached over 2,800 patients in its initial 12-month roll-out period and was effective in linking nearly 80% of patients assisted to resources. Adoption of the CHWI intervention components varied by participating clinical team, with no difference in referral rates between clinical teams with and without a clinician champion present. Implementation of CHW referrals via the electronic referral order from clinicians and initial contact by CHWs was overall successful and timely. Maintaining CHWs in our health system will require more sustainable funding as adoption of the program expands; however, the median cost per patient provides a baseline cost estimate to prepare for future reimbursement and value-based payment models. This evaluation expands and adds to existing knowledge of assessing real-world implementation of social prescribing interventions. In 2022, the RE-AIM framework was utilized to evaluate a similar ambulatory social care program, which reached 34% of patients who screened positive for HRSNs and connected 75% of participants to social services (29). This program is comparable in scale to the catchment population of the CHWI but limited to pediatric settings. Additional programs focused on CHWs and HRSNs have demonstrated varying estimates of reach but at smaller scale (16) and within different settings (30). Preliminary results from the largest HRSN screening and referral program in the US, the American Health Communities (AHC) Model, have demonstrated a much higher acceptance rate, reaching closer to 80% of eligible participants (31). This model, however, has also suggested that HRSN navigation alone is not effective in increasing connection to social services or resolving social needs (31). There were significant barriers noted by beneficiaries and service providers in accessing or confirming connection to services that likely contributed to the effectiveness of HRSN navigation. Additionally, services accessed were not always enough to meet the needs of the beneficiaries. Recommendations from this study include assessing and investing in local community service provider capacity and exploring additional mechanisms, other than addressing HRSNs, through which navigation programs may contribute to health outcomes. Our experience has suggested that effective integration of CHWs within health systems is challenging as the role is often novel with ambiguous roles and scope. Prior to engagement with CHWs, clinical teams may struggle with understanding the CHW role or experience conflict while transitioning from traditional care models (32). In a qualitative study in Chicago, higher levels of CHW integration were found in clinical teams with greater alignment in CHW purpose and value perspectives across administrators, clinicians, and CHWs (33). Despite the finding that clinician champions were not associated with adoption of CHW referrals, these staff members have increased access and opportunity to educate other clinicians on the purpose and value of the CHWI referral program. Additionally, their participation in the program may demonstrate a significant impact on the referral rate with time and expansion. Few studies have successfully demonstrated the direct economic impact of CHW interventions. In a recent analysis as part of a RCT in Pennsylvania, the CHW program demonstrated an annual return of $ 2.47 for every dollar invested annually by Medicaid, which further incentivizes state Medicaid programs and health systems to invest in CHW programs to improve health outcomes, address HRSNs, and lower costs (34). Several states have started utilizing CHW services to address population health needs and have authorized their payments through Medicaid programs (35). In 2023, CMS announced that health care providers would be reimbursed for CHW services for the first time in New York State (NYS). This funding was initially limited to pregnant and postpartum individuals but will be expanded to children and adults with HRSNs in 2024, which will directly impact the maintenance of the CHWI (36). In NYS, CHWs will be reimbursed at a rate of $ 35.00 per Medicaid member for individual education and training sessions, with 12 annual sessions allowed for adults and 24 for children (37). The CHWI developed its maintenance measure based on the number of patients served per year rather than the number of sessions administered, given that it does not currently limit the number of sessions per patient. Additionally, the CHWI does not administer group navigation sessions, for which Medicaid also offers rates of reimbursement (37). These are factors that the CHWI model may need to consider adapting or may need to advocate against as non-practical elements of the Medicaid-reimbursement model. There are additional opportunities for sustainable funding in NYS to expand the CHWI, including the Section 1115 waiver and shift from Fee for Service towards Value Based Payment models (35). As new models are released and updated, it is important that we continue to compare our baseline cost estimates to determine the need for future adaptation and advocacy work. Limitations This study has several limitations to address. First, patients with self-reported HRSNs identified in the screening tool are not representative of all active patients with HRSNs in the health system. Although universal screening is recommended, clinical teams have the discretion to screen their patient population based on pre-defined intervals or eligibility criteria. Additionally, patients who do complete the screen may not self-report HRSNs due to a lack of trust in the health care system (38). As previously mentioned, patients may also self-report HRSNs directly to the clinician or CHW without being screened; however, there is currently no documentation of these patients unless the patient requests assistance and the clinician sends an electronic referral order or the CHW completes the first outreach attempt. There are also limitations in documenting patients who self-report HRSNs in the screening tool but do not request assistance with HRSNs. We are able to document rates of acceptance for these patients; however, this measure is not widely utilized with significant missing data observed (39). We also do not have data available for patients who requested assistance and were referred to the EHR-supported social service directory when a CHW was not available. There are additional limitations related to the workflow between clinicians and CHWs. The health system recommends, but does not require, that clinicians screen patients for HRSNs prior to completing an electronic referral order. Therefore, not all patients referred will be identified as eligible in the EHR screening database. Additionally, there are challenges in matching the EHR database with the REDCap CHWI database due to lag times between screening, electronic referral order, and first CHW contact dates. Finally, data collection for HRSN screening and CHW referrals were conducted by non-research staff as part of routine service delivery. Although data entry safeguards were utilized and data were regularly reviewed by investigators, there is potential for misclassification bias and data entry errors. Our process and outcome measures have specific limitations given the nature of social service referrals. We define success according to the CHWs ability to facilitate connection to services rather than the patient’s actual receipt of benefits, which is challenged by the barriers and limitations of the social service industry. This definition may overestimate the “true” magnitude of our interventions effect on HRSNs. On the other hand, we define effectiveness as unsuccessful when patients are disconnected from CHWs, which may underestimate that same effect. Conclusions We conducted an implementation evaluation of a real-world CHW intervention aimed at connecting patients with HRSNs to social services. Despite significant proportions of patients both connecting to social services and reporting progress or resolution of HRSNs after receipt of CHW assistance, there is more optimization work ahead. We need to better understand why a meaningful proportion of patients either decline assistance or are not successfully connected to CHW navigation services. Furthermore, we need more rigorous costing assessments to understand how health systems can sustain this workforce. The shift of health systems to improve social care integration portends improved health outcomes and reduced health disparities, but there is more research and learning required to achieve these goals. Abbreviations health-related social need (HRSN); social determinants of health (SDoH); community health worker (CHW); randomized control trial (RCT); Community Health Worker Institute (CHWI); Community Linkage to Care (CLC); electronic health record (EHR); Research Electronic Data Capture (REDCap) Declarations Ethics approval and consent to participate : All research was approved by the Albert Einstein College of Medicine Institutional Review Board (2017-8434). The Albert Einstein College of Medicine Institutional Review Board granted our study a waiver of informed consent since this was a retrospective, cross-sectional analysis of data routinely collected by the health system. Consent for publication : Not applicable. Availability of data and materials : The de-identified datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors have no conflicts of interest to disclose. Funding : Support for this work was provided by the New York Health Foundation, Doris Duke Charitable Foundation (2023-0258) and the Harold and Muriel Block Institute for Clinical and Translational Research at Einstein and Montefiore (UL1TR002556) . Authors' contributions : KPF contributed to the study design; SL analyzed the data; SL contributed to literature review; SL, KPF, and JH contributed to writing of the manuscript. KPF, SL, JH, RW, AT, HM, KV, ECC, and AR read, reviewed, and approved the final manuscript. read, reviewed, and approved the final manuscript. Acknowledgements : The authors would like to acknowledge the role of many CHWI program partners including team members from the Montefiore Office of Community and Population Health; Montefiore Medical Group leadership and analytics team for developing the screening tool and integrating it within the electronic health record; Hostos Community College for partnering with CHWI to train CHWs and build sustainable healthcare careers for local community members; CHWI programs team for recruiting, training, managing, and leading a skilled and insightful team of CHWs; CHWs for always going above and beyond to find resources and assist our patients; and the staff and patients at Montefiore Health System for supporting this new initiative. References Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington (DC): The National Academies of Sciences, Engineering, and Medicine; 2019. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization; 2010. County Health Rankings Model: Health Factors: University of Wisconsin Population Health Institute; 2023 [Available from: https://www.countyhealthrankings.org/explore-health-rankings/county-health-rankings-model/health-factors? Whitman A, Lew ND, Chappel A, Aysola V, Zuckerman R, Sommers BD. Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. 2022. Kreuter MW, Thompson T, McQueen A, Garg R. Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health. Annu Rev Public Health. 2021;42:329-44. Gottlieb L, Cottrell EK, Park B, Clark KD, Gold R, Fichtenberg C. Advancing Social Prescribing with Implementation Science. J Am Board Fam Med. 2018;31(3):315-21. The CMS Framework for Health Equity (2022-2032). Baltimore, MD: Centers for Medicare & Medicaid Services; 2022. New Requirements to Reduce Health Care Disparities. The Joint Commission; 2022. APHA. Community Health Workers: APHA; [Available from: https://www.apha.org/apha-communities/member-sections/community-health-workers. Brown O, Kangovi S, Wiggins N, Alvarado CS. Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings. NAM Perspect. 2020;2020. Knowles M, Crowley AP, Vasan A, Kangovi S. Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States. Annu Rev Public Health. 2023;44:363-81. Kangovi S, Mitra N, Norton L, Harte R, Zhao X, Carter T, et al. Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial. JAMA Intern Med. 2018;178(12):1635-43. Patel MI, Kapphahn K, Wood E, Coker T, Salava D, Riley A, et al. Effect of a Community Health Worker-Led Intervention Among Low-Income and Minoritized Patients With Cancer: A Randomized Clinical Trial. J Clin Oncol. 2023:JCO2300309. Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, et al. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern Med. 2014;174(4):535-43. Gottlieb LM, Hessler D, Long D, Laves E, Burns AR, Amaya A, et al. Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA Pediatr. 2016;170(11):e162521. Schechter SB, Lakhaney D, Peretz PJ, Matiz LA. Community Health Worker Intervention to Address Social Determinants of Health for Children Hospitalized With Asthma. Hosp Pediatr. 2021;11(12):1370-6. Matiz LA, Leong S, Peretz PJ, Kuhlmey M, Bernstein SA, Oliver MA, et al. Integrating community health workers into a community hearing health collaborative to understand the social determinants of health in children with hearing loss. Disabil Health J. 2022;15(1):101181. Flike K, Means RH, Chou J, Shi L, Hayman LL. Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness. Health Promot Pract. 2023:15248399231192992. In: Olsen L, Aisner D, McGinnis JM, editors. The Learning Healthcare System: Workshop Summary. Washington (DC)2007. QuickFacts: Bronx County, New York 2022 [Available from: https://www.census.gov/quickfacts/fact/table/bronxcountynewyork/PST045222. MMC. Community Health Needs AssessmentImplementation Strategy Report and Community Service Plan 2022-2024. 2022. Fiori KP, Rehm CD, Sanderson D, Braganza S, Parsons A, Chodon T, et al. Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program. Clin Pediatr (Phila). 2020;59(6):547-56. HealthLeads. The Health Leads Screening Toolkit 2023 [Available from: https://healthleadsusa.org/news-resources/the-health-leads-screening-toolkit/. Fiori KP, Heller CG, Flattau A, Harris-Hollingsworth NR, Parsons A, Rinke ML, et al. Scaling-up social needs screening in practice: a retrospective, cross-sectional analysis of data from electronic health records from Bronx county, New York, USA. BMJ Open. 2021;11(9):e053633. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81. Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health. 2019;7:64. Berman RS, Nguyen HT, Levano SR, Fiori KP. Clinician Champions' Influence on Social Needs Screening Volumes in Pediatric Practices. Clin Pediatr (Phila). 2023:99228231200404. DeCamp LR, Yousuf S, Peters C, Cruze E, Kutchman E. Assessing Strengths, Challenges, and Equity Via Pragmatic Evaluation of a Social Care Program. Acad Pediatr. 2023. Foster AA, Daly CJ, Leong R, Stoll J, Butler M, Jacobs DM. Integrating community health workers within a pharmacy to address health-related social needs. J Am Pharm Assoc (2003). 2023;63(3):799-806 e3. Renaud J, McClellan SR, DePriest K, Witgert K, O'Connor S, Abowd Johnson K, et al. Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities. Health Aff (Millwood). 2023;42(6):832-40. Washburn DJ, Callaghan T, Schmit C, Thompson E, Martinez D, Lafleur M. Community health worker roles and their evolving interprofessional relationships in the United States. J Interprof Care. 2022;36(4):545-51. McCarville EE, Martin MA, Pratap PL, Pinsker E, Seweryn SM, Peters KE. Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study. BMC Health Serv Res. 2022;22(1):1587. Kangovi S, Mitra N, Grande D, Long JA, Asch DA. Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment. Health Aff (Millwood). 2020;39(2):207-13. Haldar S, Hinton E. State Policies for Expanding Medicaid Coverage of Community Health Worker (CHW) Services: KFF; 2023 [Available from: https://www.kff.org/medicaid/issue-brief/state-policies-for-expanding-medicaid-coverage-of-community-health-worker-chw-services/. Assembly Bill A3007C, STATE OF NEW YORK, 2023-2024 Legislative Session Sess. (2023). NYCDOH. Community Health Worker Services Policy Manual. 2023. Armstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-reported health in the United States. J Gen Intern Med. 2006;21(4):292-7. Shi M, Fiori K, Kim RS, Gao Q, Umanski G, Thomas I, et al. Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System. J Prim Care Community Health. 2023;14:21501319231166918. Additional Declarations No competing interests reported. Supplementary Files CHSLManuscriptCHWIYear1EvalSupplemental.docx Cite Share Download PDF Status: Published Journal Publication published 27 Apr, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 19 Mar, 2024 Reviews received at journal 14 Mar, 2024 Reviews received at journal 06 Mar, 2024 Reviewers agreed at journal 25 Feb, 2024 Reviewers agreed at journal 18 Feb, 2024 Reviewers invited by journal 15 Feb, 2024 Editor assigned by journal 13 Feb, 2024 Submission checks completed at journal 13 Feb, 2024 First submitted to journal 09 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Health-related social needs (HRSN) represent the self-reported individual experiences of social risk factors at a particular moment in time (1). These HRSNs are distinct from the broader, structural social determinants of health (SDoH), which are defined by the World Health Organization as \u0026ldquo;the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life\u0026rdquo; (2). In recent years, health systems have expanded their focus from access and quality of health care to include screening for and addressing HRSNs, which can influence more than 50% of a patient\u0026rsquo;s health (3). Increasing clinical teams\u0026rsquo; awareness of HRSNs is an important first step in addressing health disparities, as outlined by the National Academies of Sciences, Engineering, and Medicine (NASEM) (1). Health systems have primarily integrated awareness activities by screening patients for HSRNs such as housing stability, food security, or transportation access (4).\u003c/p\u003e \u003cp\u003eThere remain clear gaps in how to best provide assistance once patients report HRSNs (5). Health systems have demonstrated variability in linking patients with HRSNs to appropriate resources and social service providers, also known as \u0026ldquo;social prescribing\u0026rdquo; (6). These decisions have recently shifted from the health system to regulatory agencies, which have identified HRSN screening and referral as an emerging priority. The Centers for Medicare \u0026amp; Medicaid Services (CMS) released new health equity measures, which mandate reporting and screening of key SDoH domains in inpatient settings in 2024 (7). Meanwhile, the Joint Commission now requires health systems to screen patients for HRSNs as well as to address the HRSNs identified through a defined action plan (8).\u003c/p\u003e \u003cp\u003eSocial prescribing activities may include referrals to onsite resources or community-based organizations, and involve nurses, social workers, student volunteers, or community health workers (6). Community health workers (CHWs) are frontline public health workers with deep understanding of, and trust within local communities (9). CHWs often serve as intermediaries between health care provider institutions, social services, and the community because they are uniquely positioned to facilitate access to resources, improve cultural competence of care delivery, strengthen patient self-sufficiency, and support communities in addressing the underlying causes of health disparities (10).\u003c/p\u003e \u003cp\u003eThere is evidence supporting the effectiveness of CHW interventions in the US in improving patient care, reducing cost of care, and advancing health equity (11); however, few studies have evaluated the impact of CHWs on HRSNs in real world practice. Previous randomized control trials (RCTs) examining CHW social prescribing interventions have reported reduced hospitalizations (12), improved health-related quality of life (13), improved access to primary care after hospitalization (14), and improved child health status (15) when compared to usual care. Additional CHW interventions have focused evaluations on the resolution of social needs (15) and connection to essential social services (16, 17, 18). There is a demonstrated gap in understanding how a large health system can successfully integrate an enterprise wide CHW program into clinical practice. This study\u0026rsquo;s objective was to describe and evaluate a health system\u0026rsquo;s 12-month experience integrating CHWs within clinical teams to address HRSNs among primary care patients in a large, multi-cultural, resource-constrained system in Bronx County, NY.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThe Community Health Worker Institute (CHWI) at Montefiore Medical Center strives to improve health equity by optimizing the integration of CHWs within clinical care teams using a learning health system approach (19). CHWs serve as a bridge between social and clinical care by addressing HRSNs and improving access to healthcare for disadvantaged populations. The CHWI centralizes recruitment, training, continuing professional development, and deployment of CHWs embedded within the health system.\u003c/p\u003e \u003cp\u003eMontefiore Medical Center primarily serves patients from Bronx County, New York, which is home to more than 1.3\u0026nbsp;million people (20). It is one of the most diverse counties in the US, with 56.6% of its residents identifying as Hispanic and 44.3% as non-Hispanic Black. Bronx County consistently ranks among the least healthy counties in New York State in measures of health factors and health outcomes (3). In spite of these challenges, the Bronx also has many assets and resources including access to higher education, healthcare facilities, open spaces, and community- and faith-based organizations (21).\u003c/p\u003e \u003cp\u003eThe CHWI builds on an initial pilot, the Community Linkage to Care (CLC) program, which modeled standardized HRSN screening and referral support in our health system in 2017 (22). As part of the CLC program, the health system implemented a 10-item HRSN screening tool adapted from the Health Leads Toolkit (Supplemental Fig.\u0026nbsp;1) (23). Clinicians reviewed the results of the screen with patients who self-reported at least one HRSN, and then asked the patient and their family members whether they were interested in receiving assistance with their HRSNs. If assistance was requested, clinicians would send an electronic referral order within the health system\u0026rsquo;s electronic health record (EHR) to facilitate connection to CHWs. If assistance was requested but a CHW was not available, clinical teams would utilize the health system\u0026rsquo;s EHR-supported social service directory to find available resources to refer patients to in their local community.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSupplemental Fig.\u0026nbsp;1. Health-Related Social Needs Screening Tool, December 2019 \u0026ndash; October 2023\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn 2022, the health system centralized CHW operations within the CHWI structure, representing a novel and enhanced investment towards CHW integration within the health system. In prior work, we have demonstrated the successful reach and adoption of the HRSN screening arm of the CLC program (24). This study aims to evaluate the centralized CHW referral component of the program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design \u0026amp; Data Sources\u003c/h2\u003e \u003cp\u003eThis retrospective, cross-sectional study utilized data collected and managed through Research Electronic Data Capture (REDCap) tools to assess the integration of CHWs across the health system. REDCap is a secure, web-based software platform hosted at Albert Einstein College of Medicine, which is designed to support data capture for research studies (25, 26). The CHWI REDCap database is a tool designed for CHWs to routinely collect data on patient demographics, referral information, outreach encounters, social need services provided, and key program outcomes. This database was internally developed and has been continually updated by the CHWI team as part of our learning health system approach. Since the launch of CHWI, we have added new services offered in the community, integrated REDCap data access groups for CHW training, automated data entry processes for follow-up encounters, linked family members through unique record numbers, and streamlined reports to track patients with ongoing follow-up needed.\u003c/p\u003e \u003cp\u003eAdditional data was extracted from the EHR to identify patients eligible to be referred to CHWs through HRSN screening and electronic referral order databases. All EHR data was extracted using Microsoft SQL Server, version 18, to query data from the Epic Electronic Health Record Data Warehouse.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003ePatients were eligible for inclusion in the analysis if they were referred to a CHW for HRSN service navigation and support within participating clinical teams and the first outreach was attempted by a CHW between October 2022 and September 2023. This time period reflects when the CHWI deployed its first cohort of CHWs within the system. Patients were initially referred to a CHW if they met the following eligibility criteria: 1) self-reported HRSNs by a standardized screening tool and requested assistance from a clinician, 2) self-reported HRSNs during the clinician visit and requested assistance from a clinician without being screened, or 3) self-reported HRSNs and requested assistance directly from the CHW, if on-site, without being screened. If the patient requested assistance directly from the CHW, the CHW would meet with the patient, contact the patient\u0026rsquo;s primary clinician, and request that the clinician retroactively submit an electronic referral order. We focused on an initial 12-month period to account for seasonality with additional follow-up outreach and outcomes for the patient after September 2023 being excluded from the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy Measures\u003c/h2\u003e \u003cp\u003eWe organized both process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (27). This framework facilitated and organized assessments of implementation with the study period. We utilized data from five ambulatory pediatric and five ambulatory internal medicine clinical teams that were actively participating in this initiative during the study period. All process and outcome measures were focused on these ten clinical teams.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRE-AIM Community Health Worker Institute (CHWI) Program Components, Measures, and Key Data Sources\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Data Sources\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR1: % of eligible patients screened positive for HRSNs who were referred to a CHW\u003c/p\u003e \u003cp\u003eR2: total number of eligible patients referred to a CHW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; EHR HRSN Screening Database\u003c/p\u003e \u003cp\u003e\u0026bull; CHWI REDCap Database\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE1. % of eligible patients connected to at least one social service\u003c/p\u003e \u003cp\u003eE2. % of eligible patients who self-reported resolution of progress on at least on HRSN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; CHWI REDCap Database\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA1. % of eligible patients screened positive for HRSNs who were referred to a CHW by clinical team\u003c/p\u003e \u003cp\u003eA2. % of clinical teams with a clinical champion present during the study period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; EHR HRSN Screening Database\u003c/p\u003e \u003cp\u003e\u0026bull; CHWI REDCap Database\u003c/p\u003e \u003cp\u003e\u0026bull; Clinician Champion Tracking Sheet\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI1. % of referrals received via electronic referral order entered into CHWI database\u003c/p\u003e \u003cp\u003eI2. median time, in days, between the electronic referral order date and first CHW contact date\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; EHR Electronic Referral Order Database\u003c/p\u003e \u003cp\u003e\u0026bull; CHWI REDCap Database\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintenance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM1. median monthly cost per household per CHW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Health System Operations Budget\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReach\u003c/h2\u003e \u003cp\u003eWe defined reach as the 1) proportion of patients with self-reported HRSNs in the screening tool who were referred to and contacted by a CHW (i.e., eligibility criteria 1 only) and 2) the total number of patients who self-reported HRSNs by any means and were referred to and contacted by a CHW (i.e., eligibility criteria 1, 2, and 3). Patients were eligible to be referred to a CHW if they self-reported HRSNs with or without a screener; therefore, the second reach measure estimates the absolute coverage of the CHWI program. We utilized the first reach measure to estimate the potential drop-off between initial self-report of HRSNs and first attempted contact by the CHW because the screening tool provides the only standardized documentation of patients with self-reported HRSNs who may decline assistance from a CHW prior to the clinician electronic referral order.\u003c/p\u003e \u003cp\u003eTo determine the proportion of patients eligible to be referred and contacted, we matched patients with self-reported HRSNs in the screening tool from the clinical teams of interest between October 2022 and September 2023 with patients contacted by CHWs from those clinical teams during the same time period using unique identifiers. For the second reach measure, we calculated the total number of patients contacted by CHWs from these clinical teams during the study period, since not all patients referred may have been screened using the standardized tool.\u003c/p\u003e \u003cp\u003e For the total patients referred and contacted, we further described their referral status based on their stage in the initial contact and consent process. We reported socio-demographic covariates, including age at referral, gender, race/ethnicity, and preferred spoken language, which were collected and documented by CHWs in the CHWI REDCap Database.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEffectiveness\u003c/h3\u003e\n\u003cp\u003eWe defined our primary effectiveness measure as the proportion of patients assisted with HRSNs for which the CHW completed all necessary steps, per program workflows, to connect the patient to at least one social service. We also defined a secondary effectiveness measure as the proportion of patients reporting connection to at least one social service who resolved or made progress on at least one HRSN. This secondary measure was self-reported by the patient and only answered after both the CHW and the patient completed all the necessary steps to be connected to at least one social service. These measures were based on internally standardized definitions for all social needs and services (Supplemental Table\u0026nbsp;1).\u003c/p\u003e\n\n\u003ch3\u003eAdoption\u003c/h3\u003e\n\u003cp\u003eAdoption of the intervention was measured according to two measures, 1) the proportion patients with self-reported HRSNs in the screening tool who were referred to and contacted by a CHW by each clinical team and 2) the proportion of clinical teams establishing a clinician champion as recommended by the intervention. Clinician champions were defined as \u0026ldquo;full-time clinicians based at practice who serve as a clinical contact, mentor, and/or coach to support CHW team integration and lead performance improvement initiatives,\u0026rdquo; and have been previously demonstrated to increase screening rates in our health system (22, 28). We used two sample T-tests to estimate whether the proportion of patients referred and contacted differed for clinical teams with and without clinician champions present.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImplementation\u003c/h2\u003e \u003cp\u003eImplementation measures included fidelity measures of the extent to which clinical teams and CHWs adhered to recommended, established workflows. These measures included 1) the proportion of patients with electronic referral orders who were referred to and contacted by a CHW, and 2) the median time, in days, between the clinician\u0026rsquo;s electronic referral order and the first CHW outreach attempt. It was an operational expectation by the CHWI for CHWs to contact patients within 7 days of the electronic referral order by a clinician. The CHWI also encouraged clinicians to complete a warm handoff, or transfer of care, with the CHW after the on-site clinical visit as part of their standardized workflow. Due to potential delays in the documentation of the electronic referral orders in the EHR, we confirmed the utilization of a warm handoff in the CHWI REDCap Database and assigned the time between the order date and first outreach as 0 days for these cases. We excluded all other observations when the first CHW outreach attempt was dated prior to the electronic referral order date.\u003c/p\u003e \u003cp\u003eWe did not assess time between the HRSN screen and electronic referral order since this is dependent solely on the clinician placing an order. To determine the proportion of patients with electronic referral orders contacted, we matched the EHR electronic referral order and CHWI REDCap databases using unique identifiers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMaintenance\u003c/h2\u003e \u003cp\u003eMaintenance was defined as the cost to sustain the CHWI intervention over time given the need to establish an estimated ongoing annual cost per beneficiary. This was measured by estimating the median annual cost to the health system per patient referred to a CHW. We first determined the annual patient count for each CHW and annual cost per CHW based on standardized CHWI salary estimates and time contributed by each CHW during the annualized study period. We then calculated the annual cost to the health system per patient for each CHW by dividing the annual patient count by the annual cost per CHW. Next, we calculated the weighted median annual cost to the health system per patient across the study period, with weights based on the proportion of months that the CHW participated in the intervention. We excluded observations for CHWs if they contributed partial data due to mid-month deployment or departure, provided only supplemental coverage to the clinical teams of interest, or demonstrated abnormal data due to performance concerns.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eWe used both descriptive and inferential statistics to summarize socio-demographic characteristics of patients referred and RE-AIM process and outcome measures. All descriptive and inferential statistics were conducted in SAS version 9.4. Weighted estimates for the Maintenance measure were calculated using PROC MEANS in SAS. All research was approved by the Albert Einstein College of Medicine Institutional Review Board (2017\u0026ndash;8434).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReach\u003c/h2\u003e \u003cp\u003eBetween October 2022 and September 2023, 25,996 unique patients were screened for HRSNs within the ten participating clinical teams using the screening tool, with 4,420 (17.0%) reporting at least one unmet HRSN. Of the patients who self-reported HRSNs in the screening tool, 1,245 were successfully referred to and contacted by (i.e., completed the first outreach attempt) CHWs integrated within these clinical teams during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician (i.e., eligibility criteria 2) or CHW (i.e., eligibility criteria 3) and were referred to CHWs who attempted the first outreach.\u003c/p\u003e \u003cp\u003eWe summarized the socio-demographic characteristics of the total referred population (n\u0026thinsp;=\u0026thinsp;2,804) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most patients referred were between 0 and 5 years of age (27.7%) followed by those between 30 and 64 years (23.9%). There were more women (55.7%) than men referred (43.8%). Referred patients most identified as Hispanic (42.4%) or Non-Hispanic Black (28.2%), with many patients declining to report their race or ethnicity (22.0%). Most patients preferred English as their primary language (74.3%) followed by Spanish (21.6%). There were 2,993 total HRSNs reported with the most reported HRSNs identified as housing security (24.7%), food security, (20.3%) and financial benefits (16.9%), respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Characteristics of Patients with Self-Reported Health-Related Social Needs Referred to Community Health Worker Institute, October 2022- September 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Patients Referred (n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,804 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e777 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e487 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e333 (11.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e670 (23.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e397 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,227 (43.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,562 (55.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender Man\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender Woman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Non-Conforming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeclined to Report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace and Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1189 (42.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e792 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic Asian / Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic American Indian / Alaskan Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeclined to Report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e618 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred Spoken Language\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,084 (74.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpanish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e605 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilingual, Spanish or English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Reported Health-Related Social Needs (HRSNs) of Patients Referred to the Community Health Worker Institute, October 2022- September 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal HRSNs Identified (n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal HRSNs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,993 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing Security\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e739 (24.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing Quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial Benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e505 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood Security\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e607 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare Coordination \u0026amp; Navigation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferral to Health Homes Program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegal Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e168 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth \u0026amp; Family Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferral to Primary Care Provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Need\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were 2,804 total patients referred from these clinical teams with the first outreach attempt completed by CHWs between October 2022 and September 2023. These patients were referred to a total of 28 CHWs, who each contributed a median of 3.0 months (IQR 2.0\u0026ndash;6.5 months) during the 12-month study period. Of the patients referred with attempted contacted, 1,939 (69.2%) were successfully contacted and consented to work with a CHW to address self-reported HRSNs. An additional 124 (4.4%) patients were successfully contacted but have yet to consent to CHW assistance, 329 (11.7%) were successfully contacted but declined CHW assistance, 336 (12.0%) were disconnected after three or more unsuccessful initial outreach attempts, and 76 (2.7%) patients were still awaiting successful initial contact by a CHW (i.e., have not three or more initial outreach attempts) at the time of data analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness\u003c/h2\u003e \u003cp\u003eWe measured CHW effectiveness through patient reported connection to social services. Overall, 1,515 (78.1%) of the 1,939 patients assisted received social services. Meanwhile, 13 (0.7%) patients failed to connect to services or were lost to follow-up before services could be confirmed. The remaining 411 (21.2%) patients are still actively working with a CHW at the time of study end period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the patients who were connected to a social service, 779 (93.3%) reported that their HRSN was improved or fully resolved. Approximately 56 (6.7%) patients reported that they failed to make progress on their HRSN or were not able to document progress because they were disconnected from care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAdoption\u003c/h2\u003e \u003cp\u003eIn our health system, every clinical team approached during the study period integrated CHWs into their team for HSRN navigation. Of the ten clinical teams, adoption of the referral component of the intervention varied with a range of 6.4\u0026ndash;72.4% of eligible patients referred to a CHW, with a median referral rate of 27.8% (IQR 14.9\u0026ndash;44.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). We also measured adoption of a key aspect of the intervention, the adoption of a clinician champion within the team. Approximately 80% (n\u0026thinsp;=\u0026thinsp;8) of clinical teams had recruited or retained a clinician champion during the study period to collaborate with the CHWI program team, educate other clinicians on the referral process, and discuss barriers and facilitators to implementation. There was no difference in the average rate of referral usage between clinical teams with (80%) and without (20%) a clinician champion present (p\u0026thinsp;=\u0026thinsp;0.50).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdoption of the Community Health Worker Institute Referral Program by Participating Clinical Teams, October 2022- September 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician Champion Present\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Patients with Self-Reported HRSNs in Screening Tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of Patients Referred to and Contacted by CHW\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercent of Patients Referred to and Contacted by CHWs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Team 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian 22.2%\u003c/p\u003e \u003cp\u003e(IQR 13.3\u0026ndash;39.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplementation\u003c/h2\u003e \u003cp\u003eThere were 3,316 patients with electronic referral orders sent by clinicians, after self-reporting HRSNs in the screening tool or directly to a clinician or CHW, between October 2022 and September 2023. CHWs completed the first outreach attempt for 2,427 (73.2%) of these patients, who are included in our study sample, with the remaining 889 patients (26.8%) still awaiting initial outreach by a CHW at the time of data analysis. There were 377 patients, of the total 2,804 referred patients in the study sample, who were excluded in this assessment because their electronic referral orders were sent outside of the study period.\u003c/p\u003e \u003cp\u003eWe measured the time between the patient\u0026rsquo;s electronic referral order and first outreach attempt by the CHW to better understand implementation of the intervention by CHWs. The median time for CHWs to first contact the patient was 11 days (IQR 2\u0026ndash;26 days) after the electronic referral order, compared to standard CHWI expectation of 7 days. There were 273 patients whose electronic referral order and first outreach attempt were reassigned to the same day because their clinicians completed a warm handoff with the CHW, as confirmed in the CHWI REDCap Database. There were 392 patients with electronic referral orders sent after the CHW\u0026rsquo;s first outreach attempt that were excluded from this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMaintenance\u003c/h2\u003e \u003cp\u003eThere were 12 CHWs included in our assessment of median annual cost to the health system per patient to sustain the CHWI intervention. After applying analytic weights, calculated based on the number of months contributed by each CHW to the intervention, we determined that the median annual cost per patient was \u003cspan\u003e$\u003c/span\u003e184.02 (IQR \u003cspan\u003e$\u003c/span\u003e134.72 \u0026ndash; \u003cspan\u003e$\u003c/span\u003e202.12).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe CHWI reached over 2,800 patients in its initial 12-month roll-out period and was effective in linking nearly 80% of patients assisted to resources. Adoption of the CHWI intervention components varied by participating clinical team, with no difference in referral rates between clinical teams with and without a clinician champion present. Implementation of CHW referrals via the electronic referral order from clinicians and initial contact by CHWs was overall successful and timely. Maintaining CHWs in our health system will require more sustainable funding as adoption of the program expands; however, the median cost per patient provides a baseline cost estimate to prepare for future reimbursement and value-based payment models.\u003c/p\u003e \u003cp\u003eThis evaluation expands and adds to existing knowledge of assessing real-world implementation of social prescribing interventions. In 2022, the RE-AIM framework was utilized to evaluate a similar ambulatory social care program, which reached 34% of patients who screened positive for HRSNs and connected 75% of participants to social services (29). This program is comparable in scale to the catchment population of the CHWI but limited to pediatric settings. Additional programs focused on CHWs and HRSNs have demonstrated varying estimates of reach but at smaller scale (16) and within different settings (30).\u003c/p\u003e \u003cp\u003ePreliminary results from the largest HRSN screening and referral program in the US, the American Health Communities (AHC) Model, have demonstrated a much higher acceptance rate, reaching closer to 80% of eligible participants (31). This model, however, has also suggested that HRSN navigation alone is not effective in increasing connection to social services or resolving social needs (31). There were significant barriers noted by beneficiaries and service providers in accessing or confirming connection to services that likely contributed to the effectiveness of HRSN navigation. Additionally, services accessed were not always enough to meet the needs of the beneficiaries. Recommendations from this study include assessing and investing in local community service provider capacity and exploring additional mechanisms, other than addressing HRSNs, through which navigation programs may contribute to health outcomes.\u003c/p\u003e \u003cp\u003eOur experience has suggested that effective integration of CHWs within health systems is challenging as the role is often novel with ambiguous roles and scope. Prior to engagement with CHWs, clinical teams may struggle with understanding the CHW role or experience conflict while transitioning from traditional care models (32). In a qualitative study in Chicago, higher levels of CHW integration were found in clinical teams with greater alignment in CHW purpose and value perspectives across administrators, clinicians, and CHWs (33). Despite the finding that clinician champions were not associated with adoption of CHW referrals, these staff members have increased access and opportunity to educate other clinicians on the purpose and value of the CHWI referral program. Additionally, their participation in the program may demonstrate a significant impact on the referral rate with time and expansion.\u003c/p\u003e \u003cp\u003eFew studies have successfully demonstrated the direct economic impact of CHW interventions. In a recent analysis as part of a RCT in Pennsylvania, the CHW program demonstrated an annual return of \u003cspan\u003e$\u003c/span\u003e2.47 for every dollar invested annually by Medicaid, which further incentivizes state Medicaid programs and health systems to invest in CHW programs to improve health outcomes, address HRSNs, and lower costs (34). Several states have started utilizing CHW services to address population health needs and have authorized their payments through Medicaid programs (35). In 2023, CMS announced that health care providers would be reimbursed for CHW services for the first time in New York State (NYS). This funding was initially limited to pregnant and postpartum individuals but will be expanded to children and adults with HRSNs in 2024, which will directly impact the maintenance of the CHWI (36).\u003c/p\u003e \u003cp\u003eIn NYS, CHWs will be reimbursed at a rate of \u003cspan\u003e$\u003c/span\u003e35.00 per Medicaid member for individual education and training sessions, with 12 annual sessions allowed for adults and 24 for children (37). The CHWI developed its maintenance measure based on the number of patients served per year rather than the number of sessions administered, given that it does not currently limit the number of sessions per patient. Additionally, the CHWI does not administer group navigation sessions, for which Medicaid also offers rates of reimbursement (37). These are factors that the CHWI model may need to consider adapting or may need to advocate against as non-practical elements of the Medicaid-reimbursement model. There are additional opportunities for sustainable funding in NYS to expand the CHWI, including the Section 1115 waiver and shift from Fee for Service towards Value Based Payment models (35). As new models are released and updated, it is important that we continue to compare our baseline cost estimates to determine the need for future adaptation and advocacy work.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations to address. First, patients with self-reported HRSNs identified in the screening tool are not representative of all active patients with HRSNs in the health system. Although universal screening is recommended, clinical teams have the discretion to screen their patient population based on pre-defined intervals or eligibility criteria. Additionally, patients who do complete the screen may not self-report HRSNs due to a lack of trust in the health care system (38). As previously mentioned, patients may also self-report HRSNs directly to the clinician or CHW without being screened; however, there is currently no documentation of these patients unless the patient requests assistance and the clinician sends an electronic referral order or the CHW completes the first outreach attempt.\u003c/p\u003e \u003cp\u003eThere are also limitations in documenting patients who self-report HRSNs in the screening tool but do not request assistance with HRSNs. We are able to document rates of acceptance for these patients; however, this measure is not widely utilized with significant missing data observed (39). We also do not have data available for patients who requested assistance and were referred to the EHR-supported social service directory when a CHW was not available.\u003c/p\u003e \u003cp\u003eThere are additional limitations related to the workflow between clinicians and CHWs. The health system recommends, but does not require, that clinicians screen patients for HRSNs prior to completing an electronic referral order. Therefore, not all patients referred will be identified as eligible in the EHR screening database. Additionally, there are challenges in matching the EHR database with the REDCap CHWI database due to lag times between screening, electronic referral order, and first CHW contact dates.\u003c/p\u003e \u003cp\u003eFinally, data collection for HRSN screening and CHW referrals were conducted by non-research staff as part of routine service delivery. Although data entry safeguards were utilized and data were regularly reviewed by investigators, there is potential for misclassification bias and data entry errors. Our process and outcome measures have specific limitations given the nature of social service referrals. We define success according to the CHWs ability to facilitate connection to services rather than the patient\u0026rsquo;s actual receipt of benefits, which is challenged by the barriers and limitations of the social service industry. This definition may overestimate the \u0026ldquo;true\u0026rdquo; magnitude of our interventions effect on HRSNs. On the other hand, we define effectiveness as unsuccessful when patients are disconnected from CHWs, which may underestimate that same effect.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe conducted an implementation evaluation of a real-world CHW intervention aimed at connecting patients with HRSNs to social services. Despite significant proportions of patients both connecting to social services and reporting progress or resolution of HRSNs after receipt of CHW assistance, there is more optimization work ahead. We need to better understand why a meaningful proportion of patients either decline assistance or are not successfully connected to CHW navigation services. Furthermore, we need more rigorous costing assessments to understand how health systems can sustain this workforce. The shift of health systems to improve social care integration portends improved health outcomes and reduced health disparities, but there is more research and learning required to achieve these goals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ehealth-related social need (HRSN); social determinants of health (SDoH); community health worker (CHW); randomized control trial (RCT); Community Health Worker Institute (CHWI); Community Linkage to Care (CLC); electronic health record (EHR); Research Electronic Data Capture (REDCap)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u0026nbsp;All research was approved by the Albert Einstein College of Medicine Institutional Review Board (2017-8434). The Albert Einstein College of Medicine Institutional Review Board\u0026nbsp;granted our study a waiver of informed consent since this was a retrospective, cross-sectional analysis of data routinely collected by the health system.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;Not applicable.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e:\u0026nbsp;The de-identified datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors have no conflicts of interest to disclose.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u0026nbsp;Support for this work was provided by the New York Health Foundation,\u003cem\u003e\u0026nbsp;\u003c/em\u003eDoris Duke Charitable Foundation (2023-0258)\u0026nbsp;and the Harold and Muriel Block Institute for Clinical and Translational Research at Einstein and Montefiore \u003cstrong\u003e(UL1TR002556)\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e:\u0026nbsp;KPF contributed to the study design; SL analyzed the data; SL contributed to literature review; SL, KPF, and JH contributed to writing of the manuscript. KPF, SL, JH, RW, AT, HM, KV, ECC, and AR read, reviewed, and approved the final manuscript. read, reviewed, and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: The authors would like to acknowledge the role of many CHWI program partners including team members from the Montefiore Office of Community and Population Health; Montefiore Medical Group leadership and analytics team for developing the screening tool and integrating it within the electronic health record; Hostos Community College for partnering with CHWI to train CHWs and build\u0026nbsp;sustainable healthcare careers for local community members;\u0026nbsp;CHWI programs team for recruiting, training, managing, and leading a skilled and insightful team of CHWs; CHWs for always going above and beyond to find resources and assist our patients; and the staff and patients at Montefiore Health System for supporting this new initiative.\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIntegrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation\u0026apos;s Health. 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J Biomed Inform. 2009;42(2):377-81.\u003c/li\u003e\n\u003cli\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health. 2019;7:64.\u003c/li\u003e\n\u003cli\u003eBerman RS, Nguyen HT, Levano SR, Fiori KP. Clinician Champions\u0026apos; Influence on Social Needs Screening Volumes in Pediatric Practices. Clin Pediatr (Phila). 2023:99228231200404.\u003c/li\u003e\n\u003cli\u003eDeCamp LR, Yousuf S, Peters C, Cruze E, Kutchman E. Assessing Strengths, Challenges, and Equity Via Pragmatic Evaluation of a Social Care Program. Acad Pediatr. 2023.\u003c/li\u003e\n\u003cli\u003eFoster AA, Daly CJ, Leong R, Stoll J, Butler M, Jacobs DM. Integrating community health workers within a pharmacy to address health-related social needs. J Am Pharm Assoc (2003). 2023;63(3):799-806 e3.\u003c/li\u003e\n\u003cli\u003eRenaud J, McClellan SR, DePriest K, Witgert K, O\u0026apos;Connor S, Abowd Johnson K, et al. Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities. Health Aff (Millwood). 2023;42(6):832-40.\u003c/li\u003e\n\u003cli\u003eWashburn DJ, Callaghan T, Schmit C, Thompson E, Martinez D, Lafleur M. Community health worker roles and their evolving interprofessional relationships in the United States. J Interprof Care. 2022;36(4):545-51.\u003c/li\u003e\n\u003cli\u003eMcCarville EE, Martin MA, Pratap PL, Pinsker E, Seweryn SM, Peters KE. Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study. BMC Health Serv Res. 2022;22(1):1587.\u003c/li\u003e\n\u003cli\u003eKangovi S, Mitra N, Grande D, Long JA, Asch DA. Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment. Health Aff (Millwood). 2020;39(2):207-13.\u003c/li\u003e\n\u003cli\u003eHaldar S, Hinton E. State Policies for Expanding Medicaid Coverage of Community Health Worker (CHW) Services: KFF; 2023 [Available from: https://www.kff.org/medicaid/issue-brief/state-policies-for-expanding-medicaid-coverage-of-community-health-worker-chw-services/.\u003c/li\u003e\n\u003cli\u003eAssembly Bill A3007C, STATE OF NEW YORK, 2023-2024 Legislative Session Sess. (2023).\u003c/li\u003e\n\u003cli\u003eNYCDOH. Community Health Worker Services Policy Manual. 2023.\u003c/li\u003e\n\u003cli\u003eArmstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-reported health in the United States. J Gen Intern Med. 2006;21(4):292-7.\u003c/li\u003e\n\u003cli\u003eShi M, Fiori K, Kim RS, Gao Q, Umanski G, Thomas I, et al. Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System. J Prim Care Community Health. 2023;14:21501319231166918.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"health related social needs, community health workers, health equity, primary health care, social determinants of health, social care integration","lastPublishedDoi":"10.21203/rs.3.rs-3943675/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3943675/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn 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 care provider systems, social services, and the community. This study describes a health system\u0026rsquo;s 12-month experience integrating CHWs to navigate HRSNs among primary care patients in Bronx County, NY.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e 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\u0026thinsp;=\u0026thinsp;1,515) of patients reported receiving social services. Adoption of the CHW clinician champion varied by clinical team (median 22.2%; IQR 13.3\u0026ndash;39.0%); however, there was no difference in referral rates between those with and without a clinician champion (p\u0026thinsp;=\u0026thinsp;0.50). Implementation of CHW referrals via an electronic referral order appeared successful (73.2%) and timely (median 11 days; IQR 2\u0026ndash;26 days) compared to standard CHWI practices. Median annual cost per household per CHW for the intervention was determined to be \u003cspan\u003e$\u003c/span\u003e184.02 (IQR \u003cspan\u003e$\u003c/span\u003e134.72 \u0026ndash; \u003cspan\u003e$\u003c/span\u003e202.12).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe 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 integrating CHWs within clinical teams.\u003c/p\u003e","manuscriptTitle":"Advancing Social Care Integration in Health Systems with Community Health Workers: an Implementation Evaluation based in Bronx, New York","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-15 16:49:52","doi":"10.21203/rs.3.rs-3943675/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-19T08:30:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-14T15:57:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-07T03:42:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b0ae244d-7d9f-425e-a446-26d7d44572fa","date":"2024-02-25T21:42:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82206a40-1b45-4170-80fd-9b6cb9cee6d4","date":"2024-02-18T15:13:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-15T20:06:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-13T10:56:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-13T09:52:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-02-09T17:07:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa73cbcf-93f0-4c38-857f-98252e168eeb","owner":[],"postedDate":"February 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-01T22:46:12+00:00","versionOfRecord":{"articleIdentity":"rs-3943675","link":"https://doi.org/10.1186/s12875-024-02376-7","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-04-27 22:46:12","publishedOnDateReadable":"April 27th, 2024"},"versionCreatedAt":"2024-02-15 16:49:52","video":"","vorDoi":"10.1186/s12875-024-02376-7","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02376-7","workflowStages":[]},"version":"v1","identity":"rs-3943675","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3943675","identity":"rs-3943675","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}