More than 10,000 Households Helped by Community Health Worker Institute @ Montefiore

Bronx Voice 

June 10, 2025

BRONX - Community Health Worker Institute (CHWI) at Montefiore, a novel program that improves the wellbeing of local residents and creates new healthcare career paths, has marked a major milestone.

Since launching in 2021, the CHWI has assisted more than 10,000 Bronx households. By creating the Institute and hiring dedicated community health workers (CHWs), experts in navigating gaps between medical care and social services, a new, formidable healthcare workforce is being molded, and health outcomes of Bronx residents are tangibly improving.

Today, 34 CHWs are deployed throughout Montefiore, spanning hospitals, primary care, OB-GYN clinics and specialty care areas like Montefiore Einstein Comprehensive Cancer Center. The locations of CHWs are based on feedback to a social determinant of health (SDOH) survey, which flags when patients express challenges like housing issues or food insecurity, which negatively impact their health. 

SDOH, like inadequate access to transportation, are directly linked to missed doctor’s appointments, which causes missed opportunities to care for patients’ health needs at the primary care level. This, in turn, causes more reliance on other areas of the health system like emergency departments.

Last year, Montefiore researchers found that when a person has at least one health related social need, this can equate to more than 175,000 “no show” appointments annually. The researchers also found that when a patient has more than one health related social need, this leads to approximately $1,772 in healthcare resources like higher inappropriate or avoidable health system utilization, compared to patients without these challenges.

More than 340,000 people have been screened since 2018, making Montefiore one of the largest SDOH screening platforms in the country. According to its data, around 14% of Montefiore patients have at least one social need. After engaging with a CHW, 94% of patients reported making progress with their challenge or having their need resolved.

“The Bronx is known for being the home of the Yankees, now the number of people who have identified at least one social need can fill up the whole stadium,” said Renee Whiskey-LaLanne, M.P.H., MCHES,  associate director, CHWI, and director, Community Partnerships in the department of family and social medicine at Montefiore Health System and Albert Einstein College of Medicine. “We are not just addressing social needs; we’re hearing about health improvements like improved asthma and diabetes management. As we continue to build on this progress, our hope is for the CHWI to be viewed as another winning institution that only could have started here, in this borough.”

CREATING NEW CAREER PATHS

Around the world, CHWs have been instrumental in refining public health messages, building trusting relationships and strengthening healthcare systems, including the healthcare workforce. At Montefiore, CHWs often come from surrounding communities, and many have shared lived experiences with the patients they assist. By recruiting individuals who are experts in the Bronx, patients feel understood and better supported, while at the same time, new career paths for residents are established.

Since the CHWI inception, CHWs at Montefiore have moved up the ranks, becoming supervisors and training specialists as well as carving out paths to pursue occupations like social work, nursing, and other health or community- based professions, due to on-the-job training, educational classes and experiences CHW gain working as part of clinical teams.

“By investing in CHWs, we’re improving the overall health and well-being of Bronx residents – and creating new career options for non-medical professionals,” said Kevin Fiori, M.D., M.P.H., M.S., director of CHWI and Social Determinants of Health, as well as associate professor, Departments of Pediatrics and Family & Social Medicine at Montefiore Health System and Albert Einstein College of Medicine. “Our community isn’t just where people live and work – it is home to our greatest resource for delivering healthcare more effectively and making a real impact on people’s lives.”