Population Health Works

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Dr. Emrick's Books, Blogs, and Podcasts

Population Health Works

Imagine juggling doctor's appointments, managing health conditions, and worrying about how you'll afford groceries or if your housing situation is stable. For many in the Bronx, this isn't imaginary – it's a daily reality. But thanks to an inspiring program at Montefiore, a helping hand is reaching out right where it's needed most. Meet the Community Health Worker Institute (CHWI), born in 2021 out of a simple, powerful idea: What if trusted neighbors could help bridge the gap between medical care and the everyday challenges that impact health? Since then, this initiative has touched the lives of over 10,000 Bronx families, bringing healthcare support, hope, and practical help.

At the heart of CHWI are the Community Health Workers (CHWs) themselves. These aren't just employees; they are often residents of the very communities they serve. They get the local challenges because they've likely faced similar ones. Currently, 34 dedicated CHWs work side-by-side with doctors and nurses across Montefiore – in hospitals, local clinics, OB-GYN offices, and even specialized centers like the Montefiore Einstein Comprehensive Cancer Center. How do they know where help is needed? Montefiore listens. When patients fill out surveys, they can share struggles like finding reliable transportation, affording food, or dealing with unstable housing. These aren't small things; they're often why people miss crucial doctor's appointments. Think about it: if you can't get a ride, you can't see your doctor. Those missed visits can lead to more significant health problems down the road, often resulting in preventable emergency room trips.

The numbers paint a stark picture: Montefiore researchers found that facing even one major life challenge could contribute to over 175,000 missed appointments yearly. When someone faces multiple hurdles, it can lead to nearly $1,800 more spent per person on healthcare, often because minor problems weren't caught early. Since 2018, Montefiore has asked over 340,000 patients about these needs, discovering that about 1 in 7 faces at least one significant challenge. But here's the hopeful part: Things change when a CHW steps in. An incredible 94% of patients who worked with CHW reported making real progress or completely resolving their issue. Leaders behind CHWI put the need in perspective: "The Bronx is famous for the Yankees, right? Well, imagine Yankee Stadium filling the number of people here who've told us they need help with basic social needs. It's huge." But she quickly pivots to the positive impact: "We're not just ticking boxes on needs; we're hearing directly from people about how their health is improving – managing asthma better, getting diabetes under control. We're building something special here, and we hope CHWI becomes known as another winning team that could only start here in the Bronx."

Around the globe, community health workers are known for building trust and making health information relatable. Montefiore's approach truly embraces this. Patients feel seen, heard, and genuinely supported by hiring local experts – people who understand the borough inside and out. And the story gets even better. CHWI isn't just transforming patients' lives; it's creating meaningful careers for Bronx residents. Thanks to on-the-job training and experience, many CHWs have grown within Montefiore, becoming supervisors and trainers. Others have found pathways into social work, nursing, and other vital community-based roles. It's a true win-win: strengthening the community's health while investing in its people.

Reference

Montefiore Health System. (2025, April 4). More than 10,000 households helped by the Community Health Worker Institute at Montefiore. PR Newswire. https://www.prnewswire.com/news-releases/more-than-10-000-households-helped-by-the-community-health-worker-institute-at-montefiore-302420807.html

 

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