Primary Care

Project Title

Integrating Community Health Workers Into Primary Care Teams

Grant Amount


Priority Area

Primary Care

Date Awarded

September 22, 2023




In Progress


New York State’s approximately 7,000 community health workers (CHWs) are frontline public health workers who are trusted members of their communities.

More than half of them are people of color. CHWs have been proven to improve access to care and health outcomes, address housing and healthy food access, and lower health care costs. Increasing support for these workers in the primary care setting is one way to expand patients’ access to primary care, advance team-based care, and enhance health equity for CHWs themselves through career ladders. With a recent increase in State and federal support, primary care practices are looking to recruit more CHWs but require assistance to integrate them into care teams. Practices also need support in designing updated clinical workflows and supervisory models to help these workers productively contribute to patient care. In 2023, NYHealth awarded Montefiore Medical Center a grant to integrate CHWs into primary care practice teams by creating and evaluating a system-wide model at its medical center in the Bronx. NYHealth is also supporting a complementary initiative with the Health and Welfare Council of Long Island.

Under this grant, Montefiore will build upon its Community Health Worker Institute—a leading system-wide approach to advance the CHW workforce—to create a replicable approach to CHW hiring, supervision, integration, and billing. To lead quality improvement efforts, Montefiore will adopt a common supervisory model, develop referral workflows, configure electronic medical record fields, and recruit clinicians as CHW champions. It will also analyze barriers and facilitators of CHW integration into primary care teams. This evaluation will allow Montefiore to assess perceptions of community health workers, clinician rates of referral to CHWs, and CHWs’ impact on outcomes related to health care cost and quality. Montefiore will produce and share a toolkit of best practices, focused on topics like designing CHW workflows, that can be adapted to different types of primary care services in New York City.