Faculty Bibliography

BACKGROUND:This study describes how New York City (NYC) Health + Hospitals implemented a large-scale Community Health Worker (CHW) program in adult primary care clinics between January 2022 and December 2023 and established metrics to monitor program implementation. This study is timely as healthcare systems consider how to scale high-quality CHW programs. METHODS:We collected metrics in the following areas: (1) Workforce demographics, team structure, and training; (2) Enrolled patient demographics; (3) Patient-centered metrics, such as patient counts (e.g. patients outreached and enrolled) and engagement (e.g. median time in program, caseloads per CHW), and goals (e.g. median number of goals identified and completed). Metrics are based on standard data elements captured through CHW documentation in the electronic health record collected during program implementation. Data cleaning is completed using SQL queries and R scripts. RESULTS:In June 2023, there were a total of 97 CHW and 22 CHW Supervisor staff lines in adult primary care across 17 healthcare sites. There were 4.6 CHWs to 1 CHW supervisor on average though this ranged by facility from 1:1 to 1:6. Compared to the population that receives primary care at NYC H + H, CHWs served more African American/Black patients (40% vs. 32%) and an older patient population (35% older than 65 vs. 21% older than 65). From January 2022 to December 2023, 13,812 patients were outreached by CHWs. Of these, 9,069 (66%) were referred by clinicians, 7,331 (53%) were enrolled, and 5,044 (37%) successfully graduated. The median number of goals identified by patients was four, and the median number of goals completed with a CHW per patient was three. The top three goals were primary care engagement (47%), specialty care engagement (46%), and food insecurity (45%). CONCLUSION/CONCLUSIONS:Establishing clear implementation and process metrics helps to ensure that CHWs embedded in health systems can meaningfully engage adult patients in health care, address patient-centered goals, and connect patients to community and government services.

BACKGROUND:There were seven opioid overdoses in this New York City (NYC) federally qualified health center from December 2018 through February 2019, reflecting the rising rate of overdose deaths in NYC overall at the time. In response to these overdoses, we sought to increase the readiness of health center staff to recognize and respond to opioid overdoses and decrease stigmatizing attitudes around opioid use disorder (OUD). METHODS:An hour-long training focusing on opioid overdose response was administered to clinical and non-clinical staff of all levels at the health center. This training included didactic education on topics such as the overdose epidemic, stigma around OUD, and opioid overdose response, as well as discussion. A structured assessment was administered immediately before and following the training to evaluate change in knowledge and attitudes. Additionally, participants completed a feedback survey immediately after the training to assess acceptability. Paired t-tests and analysis of variance tests were used to assess changes in pre- and post-test scores. RESULTS:Over 76% of the health center staff participated in the training (N = 310). There were large and significant increases in mean knowledge and attitudinal scores from pre- to post-test (p < .001 and p < .001, respectively). While there was no significant effect of profession on attitudinal change scores, profession did have a significant effect on knowledge change scores, with administrative staff, non-clinical support staff, other healthcare staff, and therapists learning significantly more than providers (p < .001). The training had high acceptability among participants from diverse departments and levels. CONCLUSIONS:An interactive educational training increased staff's knowledge and readiness to respond to an overdose as well as improved attitudes toward individuals living with OUD. TRIAL REGISTRATION/BACKGROUND:This project was undertaken as a quality improvement initiative at the health center and as such was not formally supervised by the Institutional Review Board per their policies. Further, per the guidelines of the International Committee of Medical Journal Editors, registration is not necessary for clinical trials whose sole purpose is to assess an intervention's effect on providers.

Identifying and addressing patients' social health are essential to addressing health equity. Screening for social needs and connecting patients to resources in clinical settings is one way to identify and address the social factors that contribute to health. Policy makers are increasingly turning to incentivizing and requiring social needs screening and referrals to encourage health systems to identify and address patient social needs. NYC Health + Hospitals implemented and scaled social needs screening and referrals starting in 2017 across primary care clinical sites. The health system's approach was to focus on screening for patients' highest-priority needs for which there were available resources, to prioritize effective screening and referrals over universal screening, and to establish referral workflows. Implementing meaningful social needs screening and referrals requires a significant investment in creating screening workflows and in building key resources to meet patient needs.

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings.

Addressing patients' social needs is key to helping patients heal from coronavirus disease 2019 (COVID-19), preventing the spread of the virus, and reducing its disproportionate burden on low-income communities and communities of color. New York City Health + Hospitals (NYC H+H) is the city's single largest healthcare provider to Medicaid and uninsured patients. In response to the COVID-19 pandemic, NYC H+H staff developed and executed a strategy to meet patients' intensified social needs during the COVID-19 pandemic. NYC H+H identified food, housing, and income support as patients' most pressing needs and built programming to quickly connect patients to these resources. While NYC H+H was able to build on its existing foundation of strong social work support of patients, all health systems must prioritize the social needs of patients and their families to mitigate the damage of COVID-19. National and local leaders should accelerate change by developing robust policy approaches to redesign the social and economic system that reinforces structural inequity and exacerbates crises like COVID-19. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].