Bronx Program Bridges Gaps Between Medical Care and Social Services

Addressing Social Determinants of Health

• 🎯 A program in the Bronx is successfully navigating the gaps between medical care and social services.
• 💡 The initiative connects patients facing non-medical challenges, such as housing and food insecurity, with community health workers.

Patient Success Story: Earl Smith

• 🤝 Earl Smith, who is paraplegic and has a progressive lung disease, was worried about losing his apartment due to escalating rent.
• 🏥 His doctor connected him with O'Neal Downer, a community health worker at Montefiore Health System, who is helping him navigate these challenges.
• 💬 Earl feels he has known O'Neal for years, highlighting the strong personal connection formed.

Montefiore's Community Health Worker Institute

• 📊 Since 2018, Montefiore has screened over 340,000 people, finding that approximately 14% have at least one social need.
• 🚀 Developed by Dr. Kevin Fury and Renee Whiskey, the institute aims to integrate social needs assessment into routine healthcare.
• ✅ The goal is to create an environment where asking about social issues like housing is as normal as asking about a cough, recognizing their impact on health.

Program Impact and Outcomes

• ✨ After engaging with a community health worker, 94% of patients reported seeing positive results.
• 💖 O'Neal is now helping Earl find a new wheelchair, demonstrating that extra care matters beyond the numbers.
• 🏘️ Since its launch in 2021, the institute has assisted over 10,000 Bronx households.

Benefits for Health Workers

• 📈 The program also creates new career paths for community health workers, with some advancing to supervisory and training roles.