Montefiore's 90-year history of prioritizing social needs 

Situated within a remarkably diverse community in New York City's Bronx neighborhood, Montefiore Health System has long been a trailblazer in recognizing and addressing social determinants of health.

"There are quotations from people who were the president and CEO of this institution — back into the 1930s and even before — that speak directly to the issue of social needs as being determinative with regard to how a patient's health status is generated," Andrew Racine, MD, PhD, senior vice president and chief medical officer at Montefiore, told Becker's.

With a history deeply rooted in this commitment, the health system has led many innovative initiatives aimed at understanding and remedying the core social factors influencing patients' health. Montefiore first piloted social determinants of health screenings in 2016 and now operates one of the most mature social determinants of health screening and referral platforms of any U.S. health system. To date, the system has screened more than 200,000 community members. 

Individuals with social needs are paired with community health workers — who are employed by the system and embedded on clinical teams — to connect patients with appropriate social needs. The strategy is rare in an industry where most health systems secure contracts with nonprofit organizations for community health workers who do not work side by side with clinicians.

Becker's recently spoke with Dr. Racine about the system's rich legacy of prioritizing holistic patient care and ongoing social determinants of health work.

Editor's note: Responses have been lightly edited for length and clarity. 

Question: What's the secret for effectively building and scaling out programs to address patients' medical and social needs? Why do you think Montefiore has been so successful at this?  

Dr. Andrew Racine: Part of it, I think, is simply because of the legacy of this health system. We've been in the Bronx for over 100 years. And although the composition of the people who live in the Bronx has changed fairly dramatically over that time, there are certain constants with respect to this borough that the institution has been involved with from the get go. This is a challenging place to live for people, and that has always been the case. The other thing that's been a constant for the borough is that it has been, over all the period of time that Montefiore has been here, a portal of entry into the United States, which is to say that the people who live here come from all over the world and have for generations. This has always been a very culturally vibrant area of the country in which to operate.

Montefiore has a certain culture and a certain awareness of what it takes to be an effective healthcare delivery partner for people in that kind of an environment, and that has grown over time. There are quotations from people who were the president and CEO of this institution — back into the 1930s and even before — that speak directly to the issue of social needs as being determinative with regard to how a patient's health status is generated. Martin Cherkasky, MD, who was the president and CEO during the 50s and 60s, not only spoke about that, but spoke about the importance of how you deliver care in that regard. That is, you can't really depend upon the fee-for-service medicine in order to adequately meet the needs of people. You have to really have a much more holistic approach to how you deliver care. This was something that was revolutionary at the time. So part of it is just the institution itself, its history and the kinds of people who have led it throughout its entire storied history. 

One of the things about working in the Bronx is that no one ends up here by accident. They come here because this is where they want to be because of the population that I just mentioned. And that is a rewarding and exciting group of folks to work with. And so many of the people who come know that the way in which we're going to improve the health status of the people in the Bronx is not just through the care that's delivered within the four walls of the institution, but that in order to sort of get people to be in a healthier position and to maintain their health status, you have to pay attention to the things that actually drive those. As an institution that's quite aware of all of this, we have taken it upon ourselves in recent years to be very proactive with regard to how we find out about those aspects of people's lives and how we can use that information to direct them to the types of resources that are going to help address some of those things.

Q: Montefiore has one of the most mature social determinants of health screening and referral platforms in the U.S. How did this come to fruition? 

AR: Many years ago, my colleague Kevin Fiori, MD, and I began to work on a way in which we could create a screening instrument that would be most effective for the folks in our community and then embed that into our Epic EMR. We knew it had to be something, from a workflow standpoint, that was easy to use for practitioners. Once you have identified a need, there has to be a direct line to a solution. There is nothing more dissatisfying from the standpoint of a practitioner to be asked to screen for a condition that you have no way of addressing. That is a recipe for frustration and misery. So we knew we needed to partner with an outside agency that could make those linkages to community-based organizations for us.

When we established those three elements, it became fairly easy to begin the screening process. We began with pediatrics, and now it's throughout our entire ambulatory and inpatient service. We've screened over 200,000 people and that has given us enormous insight into what it is that our patient population is looking to solve from the standpoint of healthcare.

Q: Montefiore has also taken a unique approach by directly employing and embedding community health workers into clinical teams as part of its Community Health Worker Institute launched in 2021. What was the motivation behind this effort?  

AR: You can be very successful in doing the screening and you can identify the needs and you can link people on paper, if you will, to the kinds of institutions in the community that can help them. But many of our patients need something more, and that's where this Community Health Worker Institute arose. Navigating these systems is difficult, particularly when you are dealing with culturally diverse community members who speak many many different languages or are new to this country and don't know how to navigate the healthcare system.

We realized that it would be very useful to have a cadre of people who are potentially community members, but who get trained about all of these intricacies so that they can help folks navigate the system and make sure that the linkages that we're trying to establish for people actually come to fruition. This is particularly important for people with complex medical conditions or have recently been hospitalized.

Dr. Fiori felt that if we were going to do this properly, we really had to do it right. And that meant a training program that was elaborate and involved getting a degree from the local Bronx Community College with whom we partner. It means paying people a reasonable wage to do this work and incorporating them into Montefiore so they have salaries and benefits. This will not only improve their lives, but will improve the entire community. That's the kind of community-based investment that Montefiore has been pioneering for many, many years, and this is just another example.

Q: How is Montefiore planning to expand work to address SDOH and health inequities in the next year? 

AR: One is simply to continue to work on the effectiveness of these programs, making sure that the greatest number of people get screened in a variety of different places as they come into contact with our institution and are then connected with the community-based organizations they need.

We also have a responsibility to not only do this work, but to understand various aspects of it. What makes it effective? What are the things that are not effective? How do we move the whole field forward? There's a complex study of design science associated with making sure that once you've done this work, you understand its impact. We are the only major academic health center in the Bronx north of the Harlem River, so the Albert Einstein College of Medicine is an integral partner. 

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