Montefiore's 'secret sauce' for genuine care

New York City-based Montefiore Health System is working to address social determinants of health by embedding community health workers into clinical teams to connect patients with necessary social services. 

Montefiore's 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.

"By having a community health worker as part of the clinical team, they can effectively get to the root of health problems and identify real-world solutions that can significantly improve the health and well-being of our patients," Kevin Fiori, MD, a physician, researcher and director of Montefiore's Community Health Worker Institute, said in an Aug. 15 news release.  

Since launching the institute in 2021, Montefiore has conducted social determinants of health screenings for more than 190,789 individuals, about 20 percent of whom had at least one social need. Leaders also use screening results to inform where to place community health workers across the system's 10 hospitals and more than 200 outpatient care sites. 

These employees are front-line public health workers who reflect the diversity of Montefiore's patient population in the Bronx. Many times, community health workers have similar lived experiences to the patients they're working with, allowing them to connect with patients on a deeper level and uncover their social needs, according to Dr. Fiori, who also serves as associate professor of family and social medicine and professor of pediatrics at the Albert Einstein College of Medicine.

"To walk in a person's shoes and empathize about experiences is the secret sauce that is sometimes missing in U.S. healthcare — it is a genuineness that can't be fabricated, and is something we need more of," he said. "Our CHWs enable people to open up so we can learn about challenges impeding their family's health."

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