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Abstract

Objective:

The Community Health Worker Institute (CHWI) addresses health-related social needs (HRSNs) by integrating Community Health Workers (CHWs) into patient care. This study explores the barriers and facilitators to HRSN referrals and the integration of CHWs within clinical teams.

Methods:

Qualitative interviews were conducted with CHWs, CHWI program staff, and clinicians from ambulatory care clinics. Semi-structured interviews, guided by the Consolidated Framework for Implementation Research, were audio-recorded, transcribed, and analyzed using rapid qualitative methods.

Results:

Preliminary findings found that while clinicians support the CHWI and referral program, time constraints during patient visits likely hinder effective screenings and referrals. CHWs are seen as valuable advocates but continue to face challenges due to confusion about their clinical role from patients and clinicians. Hierarchical power dynamics seen between providers and CHWs likely contribute to this confusion. Clinics with strong leadership, clear role delineation, and clinical site preparation appear to have better CHW integration.

Conclusion:

CHWs play a crucial role in addressing HRSNs, but their integration into clinical teams requires overcoming logistical and educational challenges. These findings offer insights for improving the HRSN referral process and integrating CHWs into healthcare systems.

Keywords

community health underserved communities social determinants of health primary care qualitative methods

Introduction

The critical impact of social determinants of health (SDOH) has gained growing recognition within healthcare. According to the World Health Organization, SDOH are defined as “the conditions in which people are born, grow, live, work, and age,” and are shaped by the distribution of money, power, and resources at various levels, including global, national, and local.¹ Among the SDOH, there are distinct health-related social needs (HRSNs) such as housing instability, food insecurity, and access to care that significantly influence individual and community health outcomes.² Healthcare institutions are beginning to acknowledge a role in addressing non-medical needs of patients.³ Addressing these needs are essential to reducing healthcare disparities.⁴

As a result, there has been an emergence of screenings to support clinicians in identifying HRSNs in their patients. HRSN screenings collect crucial social information that can guide the allocation of resources and inform policy decisions aimed at promoting health equity.⁵ Increasingly, health systems have adopted the process of gathering data on HRSNs for electronic health records (EHR) to coordinate clinical care.^6
-8 Screening data collected from patients allows interventions to be tied to the patient’s specific needs and focuses on shared decision making.⁹ Screenings can identify unmet HRSNs and can facilitate connecting patients to community resources.¹⁰ Further research has continued to optimize HRSN screenings through improvements in efficiency, universal implementation, linkage of patients to resources, and integration into EHRs for ease of clinician use.¹¹

In parallel, Community Health Workers (CHWs) have emerged as a pivotal strategy in addressing HRSNs within healthcare systems and are recognized as vital components of the healthcare workforce.¹² CHWs empower patients to advocate for themselves and work at both the patient and institutional level to pioneer social justice. Clinicians acknowledge the role CHWs play in sharing community resources that they may be unaware of.¹³ CHWs share lived experiences with the communities they serve, creating a vital bridge between healthcare systems and patient populations.^14,15 A 2021 national survey completed by the National Association of Community Health Workers found that CHWs largely represented the communities they serve: 62.3% were Hispanic/Latino, 31.7% were Black or African American, and 4.8% were American Indian.¹⁶ Evidence suggests that CHWs play a significant role in achieving health goals and improving health outcomes in diverse communities.¹⁷ Previous studies have shown CHWs to be effective in increasing access to preventive care through cancer screenings and management of chronic health conditions such as diabetes, hypertension, and asthma.^14,18 CHWs can lessen the cost of healthcare by reducing emergency department visits and hospitalization stays.¹⁹ A study from our health system found CHWs effective in connecting over 78% of patients with social services and of those patients connected, over 93% of patients reported that their HRSN had improved or fully resolved.²⁰

Based on the growing evidence supporting HRSN screenings and the effectiveness of CHWs, the Community Health Worker Institute (CHWI) was launched. Our health system began screening patients for HRSNs in 2017 and in 2022 launched the referral to CHW component.^20
-24 The CHWI identifies and connects patients with HRSNs to CHWs who assist in addressing HRSNs (see Figure 1). When a patient screens positive on the HRSN screening, the clinician asks the patient or family if they are interested in receiving assistance with their HRSN.²⁵ Upon patient consent, the clinician refers them to a CHW through the EHR for further assistance. CHWs then reach out to the patient or family to conduct an initial evaluation, gathering demographic information, obtaining consent for service navigation, and gaining a comprehensive understanding of their HRSN. CHWs aid patients by connecting them with community-based programs, assisting with benefit applications, navigating complex medical system care coordination, increasing patient education and empowerment, and providing social support among other services. CHWs maintain ongoing communication with patients until their HRSNs are resolved, until the family no longer requires services, or until the family is disconnected after multiple contact attempts.

Figure 1.

Community Health Worker Institute Health-related social need screening to CHW referral process.

While CHWs are effective in addressing the HRSNs of patients, there is still a significant proportion of patients who are not successfully connected with CHW services.²⁰ There is high variability in referral rates across clinical sites ranging from 6.4 to 72.4% of eligible patients referred to CHWs.²⁰ Previous research in other health systems has identified the limited understanding of the CHW role by healthcare professionals to be a significant barrier to CHW integration within clinical teams.²⁶ There are no evidence-based guidelines on how to best integrate CHWs into healthcare settings along with limited research of CHWs’ personal perspectives on their integration into clinical teams.²⁷ Further research is needed to understand the variability in volume and success of referrals to CHWs across clinical teams in order to further optimize evidence-based screening and referral programs.

To explore perspectives from CHWs, program staff, and clinicians on HRSN screening and referral programs, we conducted a qualitative study in a large urban health system. The objectives were to: (1) identify the barriers and facilitators to HRSNs referrals to CHWs, and (2) assess CHW integration within clinical teams. The findings will inform improvements to and adaptations of the CHWI, with the goal of improving program delivery and CHW integration to more effectively address HRSNs. To our knowledge, this is the first study to explore perspectives from CHWs and clinicians on a CHW HRSN screening and referral program in a large health system.

Methods

Study Sample

We conducted semi-structured interviews at 2 ambulatory care sites within a large health system in the Bronx, NY. Purposeful sampling was used to capture diverse perspectives from program implementors across clinical sites.^28
-30 Participants were eligible if they were 18 years or older, English-speaking, and had a current role within the health system that included engagement with the CHWI. Participants provided informed verbal consent.

Interviews

Employing the updated Consolidated Framework for Implementation Research (CFIR), a structured implementation science framework, we collected data on the barriers and facilitators to HRSN referral and CHW integration through qualitative interviews.³¹ Semi-structured interview guides were developed based on CFIR constructs, encompassing program complexity and design, resource availability, cultural attitudes toward CHWs, communication practices, recipient needs, and adaptations (see Supplemental Table 1).³¹ All interviews were conducted via Zoom between November 2023 and February 2024, with an average duration of 30 min. Trained investigators with advanced degrees and experience with qualitative research conducted the interviews. Audio recordings were transcribed for each interview, using an intelligent verbatim technique.³²

Analysis

Two team members trained in qualitative methods (PG and JH) employed a rapid qualitative approach to analyze data.^33
-35 Each transcribed interview was coded and summarized separately by both team members.³² Transcript summaries were organized by CFIR domains including innovation, inner setting, and implementation process with corresponding constructs within each domain.³¹ Debriefing sessions were completed to reconcile any coding discrepancies, resulting in a combined and final transcript summary for each interview.³⁶ Transcript summaries included both direct quotations and paraphrased content from the interviews. Operational definitions of constructs were established between team members to facilitate the coding process. Matrix analysis was completed by analyzing data from all interviews organized by CFIR domain and constructs. Analytic memos were drafted for each CFIR domain and construct by extrapolating data from the matrix analysis summarizing key findings. Seminal quotes were elicited for key facilitators and barriers (see Supplemental Table 1). Results are organized into facilitators and barriers by CFIR domain.

Results

Participants

Ten participating completed interviews, including CHWs (n = 3), program staff (n = 3), and clinicians (n = 4). Of the 4 clinicians, 2 were pediatricians and 2 were internal medicine physicians. Program staff included 2 CHW supervisors and 1 program manager. There was an equal distribution of participants at each level from the 2 clinical teams. All participants were female with an average work history of 57.1 months. Participants were on average 34 years old with a range of educational levels. Each interview revealed valuable themes, highlighting facilitators and barriers across domains. Seminal quotes from participant interviews (Table 1) further illustrate these findings, offering deeper insight into key themes.

Table 1.

Seminal Quotes of Facilitators and Barriers to CHW Referral and Integration Organized by CFIR Domains and Constructs.

Domains (CFIR)	Facilitator	Seminal quotes
Innovation	Clinician appreciation of CHW role and contributions	“Most of the time it’s extremely positive. [Clinicians are] very interested in CHW services. They’re very interested in what that means. They’re interested in breaking cycles of poverty, generational poverty, and improving the lives of their patients. They’re very interested in that part.” (Program Staff) “I think the screening is really important because we don’t, patients don’t feel comfortable with having that information and telling their doctors that information all the time.” (Clinician)
	Clinician commitment to addressing HRSNs	“And caring in pediatrics, and in all fields of medicine, but in pediatrics we’re caring for a lot more than the very specific medical needs of the child. And a lot of medical needs are intertwined with social needs and fixing certain things that can be fixed in the sort of SDOH end of it can really contribute positively to the medical. And so I think for me, they’re very intertwined, and you really can’t separate the two. So, the fact that we have the ability to intervene or at least support families on that end is crucial.” (Clinician)
	CHW referral work queue	“I like it to be in the work queue so me and my coworker can pick it up and decide who does what, so there isn’t too much work all on me.” (CHW)“When you put the patient in the work queue it just helps the process faster. Let’s say if it’s an urgent need, and you put the patient in the queue, and you also give a CHW a call, we’re able to see the patient faster.” (Program Staff)
	CHW hands-on training	“I do like the hands-on training where I can actually know what a patient needs and where to go for resources. Hands on for me is better.” (CHW)“Our training is very extensive when it comes to CHWs, and as someone who was a CHW, I wish I had that training.” (Program Staff)
	Referral process	“The easier you make it for clinicians the better, because everyone is super busy.” (Program Staff)“Actually, putting in the referrals is very, very easy.” (Clinician)
Inner setting	Appropriate resources available for CHWs	“I’m lucky enough to have a pretty big space, so there’s two desks here, and a table. So, even patients that use like walkers or wheelchairs. It’s very accommodating.” (CHW)“I have everything I need. I have a computer where I can research if they need anything. The office space is perfect for my one-on-ones when my patients come into the office.” (CHW)
	Continuous education of clinicians by CHWs	“Most of the clinicians are pretty good once you tell them, ‘Oh we can’t do this, or this is out of our scope because of XYZ.’ We just have to explain it to them, and they kind of get it.” (CHW)“If I feel like [a referral] is inappropriate, I do send the referral to the social worker and also try to educate the doctor and remind them of what I do. It doesn’t happen often because we do receive new doctors, but we try to educate them every month. Inappropriate referrals don’t happen often, but when they do, we try to reach out.” (CHW)
	Clinician meetings prior to CHW deployment	“Making sure all of leadership is informed. Communicating this information going down. Having a clinician meeting before the CHW is deployed so that you can have everyone on the same page so they understand the process and make sure everyone understands.” (Program Staff)
	Leadership buy-in	“If a site has pretty consistent good leadership, chances are they’re gonna be great.” (Program Staff)
Implementation process	CHW presence on site	“I know sometimes our families also are difficult to reach by phone or sometimes don’t even have a working phone. So, if they were closer and you needed to do a quick, warm hand off for certain families where they may not be able to be reached by phone, then it might be more helpful.” (Clinician)
	Clinician discussion of CHW referral	“[patient acceptance of CHW referral is] higher when it’s been discussed specifically by the physician. We can at least just say ‘we have a team of people that can contact you and talk a little bit more. If there’s any way we can offer certain resources or information.’ And I’ve had some parents that are like, ‘sure, like I don’t know that they’re gonna be able to help me, but sure’, so I think that’s more probably led to an acceptance of working with the CHW.” (Clinician)“Patients trust their clinicians, so if the clinician is more open to saying, ‘Hey, you’re going to meet the CHW, they will help you.’ And they are aware of the scope of practice, it would be a much better outcome.” (Program Staff)
	Stacking patient appointments	“[Clinician] appointments are squeezed together. They do that a lot with patients that are used to missing appointments. . .it’s easier for them to come in just that one day when they stack up their appointments.” (CHW)
	Patient contact	“Majority of my patients meet over the phone.” (CHW)“It’s pretty easy to get patients over the phone. If a patient is scheduled to come in and they don’t come in, then I call them. There’s not been too many challenges.” (CHW)
Domains (CFIR)	Barrier	Seminal quotes
Innovation	Lack of CHW presence on site	“We used to have one (CHW). She was a lot more visible, and then they moved her office further away and then she left, and then we switched, and now I don’t even know where the new community health worker sits.” (Clinician)
	Confusion about CHW role	“I think the biggest. . . I don’t know mistake. But issue that we do is we refer to the social worker when we should be referring to the CHW.” (Clinician)“I would say with patients, though, they refer to me as a social worker, and I think that community health worker is like a newer term, they may not be familiar with. So social workers is just so much easier. Or sometimes they think that I can do what social workers do.” (CHW)
	Perceptions of social services	“It’s only gonna be as good as the services. So like, you can connect people to services. But if the services themselves are not good then it’s not gonna help. And I mean, I’ve definitely been a little disillusioned by government run services for high-risk patients.” (Clinician)“I think one of the biggest challenges with social needs screening and referral is that it is dependent on the services that exist in the city and available to our patients and in the community that we live in.” (Clinician)
	Referral workflow	“We have this big, huge, long after visit summary smart phrase that has all these specialties, and CHW is included in that. And we just kind of click the box and write it in the checkout note, and then hope that the front desk follows through on that and schedules the patient before they leave.” (Clinician)
	Limited time during patient visits	“Because it’s extra work on top of what [clinicians are] doing. We have to understand that they don’t get paid extra to do this and they only have 15 minutes with the patient and within that 15 minutes, clinicians have to do everything- history, meds, actual medical stuff that’s happening now, follow-up, advice, so many different things, and then, on top of that, they have to talk about all of this.” (Program Staff)
	Site preparation for CHW deployment	“Yeah, it’s been tough [integration of CHW component]. Because before a CHW is even deployed, meetings happen that don’t always include me, the supervisor.” (Program Staff)
	Paperwork and literacy	“We hand patients a lot of paperwork and the other big barriers is I think literacy levels and English is low in our patient population. So, they get all this paperwork. It’s overwhelming for them, and then it goes into their bag.” (Clinician)“One is that perhaps they’re not getting the screen. And I think there’s kind of ebbs and flows with how good, we do how well, we do on that and then 2. If they do get the screen, I think that sometimes it can be overwhelming. It’s a long form, and I think sometimes people don’t want to fill it out, and it also has sensitive information, and that might be a reason too.” (Clinician)
Inner setting	Hierarchical power dynamic	“There is a power dynamic that exists. So it’s very, very difficult sometimes for a CHW to be able to share certain things or request certain things from doctors without being super nervous.” (Program Staff)
	Clinician meeting attendance	“I’m guilty. I’m not going most of the time lately [to monthly CHWI clinician meetings].” (Clinician)“I go to huddles every day as much as I can to show my talk about my role and also answer any questions which ideally, this would be the space where people will hear me, but unfortunately, a lot of clinicians, resident doctors, nurses don’t go to huddle.” (CHW)
	Follow-up on patient connection with CHW	“So sometimes they’ll [CHWs] send me a staff message that they reached out [to patient], or whether they got them or didn’t get them, and then sometimes I’ll see in the account or if they had another visit. But it’s not something that I’m looking for specifically.” (Clinician)“Is there something else that we can be doing to ensure that they actually connect with each other, especially the ones that we’ve talked about the referral cause that that’s happened for me, for sure?” (Clinician)
	Unclear roles and high staff turnover	“I just wish that during the training they talked more about the roles of the other staff members that were at the clinic, so that, you know, we could better understand how that ties into the work that they do with the patients, and that we do with the patients. So, like doctors, nurses, front desk staff, I think. I would have appreciated a little bit more clarity on that.” (CHW)“With the turnover of staff, there were clinicians that didn’t even know what the screener was. So, there was a lot of clinician education that was required.” (Program Staff)
	Limited time for clinicians	“I don’t have time to call a parent the next day about one of those questions. So, I’m often just putting a referral in. And I do think sometimes it has been fruitful. But I know there have been other times where across multiple people who’ve had the same experience, the parent has been confused as to why there was a referral.” (Clinician)“I have a hard time getting through the medical stuff in 30 min. And then you know, certainly feel like I ask about social determinants of health just generally because they do affect, you know, medication, adherence, and things like that. But I think, to actually complete the screening and to focus on that. I think that could be a challenge.” (Clinician)“The reality is, more and more gets put on our shoulders. But nobody’s ever given us more time to do any of it, or more, you know more ability, more, system changes to actually help us focus on these things.” (Clinician)“Nobody wants to do more work than what they have, so it becomes a problem when we have some sites that are good with sending referrals, and then we have some that they’re not sending referrals at all.” (Program Staff)“I think clinicians want it, they just don’t want to be part of the equation. But that doesn’t work. You have to have both.” (Program Staff)
Implementation process	Lag time between referral and CHW contact	“When I call them they’re like, ‘Oh, well, I filled out that paper a month ago, and you’re calling me now, or that was in July, Why are you calling me in November? I don’t need help anymore.’” (CHW)“I don’t reach out to patients right away when the referral goes in, it takes like a week or two. Once I reach out to them, they may have already gotten their SNAP benefits or are okay with housing now. At that point in time they needed assistance, but they took care of things on their own and no longer need services which is okay.” (CHW)
	Patients’ unclear expectation of CHW role	“They [patients] just think I’m a social worker. So they have that narrative, and they will say all their feelings and stuff and I’m like ‘I’m not licensed for that. No, no, no!’ So they just clash it all together, they’re like ‘Oh, you’re a social worker. Okay so I could say this that you know.’” (CHW)“Some of them [patients] think that we can magically give them things. I think that we can help them facilitate [buying] a car and it’s a lot of education going on about what we can and cannot do, because I could tell them we could give referrals to access [transportation services].” (CHW)“A lot of [patients] think we can get them apartments right away. . .It’s not that we can facilitate getting the keys faster or an apartment faster, but we could give you the resources of who to contact, where to go, what to do, what to say. But they’re under the impression that we can get them like in there.” (CHW)
	CHW and patient availability	“[Patients say] ‘I’m not available during those hours. Can you call me after work, or before which I totally understand, because I’m working 9 to 5 as well.’ So it’s just difficult to accommodate the working individuals.” (CHW)
	Clinicians can miss positive SDOH screens	“I think [when] you open the chart and a screen pops up and says, patient had positive screen, and it’s right in your face, and you have to click past it in order to go to your notes. That would be helpful, and it would be annoying, and people probably wouldn’t all like it. But I think it would improve our catching the positive screens.” (Clinician)
	Migrant communities are challenging to get in touch with	“The resources for immigrants is very scarce at the moment especially, too, is that they don’t really understand my role either. I’m pretty sure the doctors tell them that they’re going to be referred to someone. But I haven’t really thought of how to better reach them, because a lot of them don’t have email addresses either.” (CHW)
	Different stages of change seen in patients	“It could be that [patients] not ready to receive the resources, or they’re not ready to actually do the work that it takes to get whatever they need. Or maybe they don’t have the time, work, I don’t know, it could be a lot of different reasons. Barriers in their life that is preventing them.” (CHW)

Abbreviations: OB/GYN: Obstetrics/Gynecology

SNAP: Supplemental Nutrition Assistance Program.

Innovation Domain

The innovation domain explores constructs related to the intervention being implemented, in this study the CHW referral and integration within clinical teams. A key innovation facilitator was a strong commitment from clinicians to collaborate with CHWs and integrate them into patient care. Clinicians recognized that information about HRSNs is often more effectively communicated by community members, and they valued the unique perspective CHWs bring to patient interactions. Clinicians demonstrated adequate understanding of the importance of addressing HRSNs, indicating broad support for the CHWI. The current workflow for CHWs to identify patients through EHR referral and the ease for clinicians to make referrals were both effective.

It has been so amazing. I am so grateful to have community health workers on our team. They provide such an integral role. There was . . .almost a year during the time I was faculty where we didn’t have a community health worker, and it was a lot more difficult for us to screen for social needs and to address social needs in our patients. So having that hands-on, on-site community health worker assistance has been so valuable. (Clinician)

There were significant barriers to innovation implementation. Clinicians reported confusion on the role of a social worker versus CHW. This same confusion was observed among patients, program staff, and CHWs. Participants reported that patients believed CHWs could offer the same services as social workers and clinicians sent inappropriate referrals to CHWs.

Sometimes patients will think I’m the social worker, so I must remind them that I’m the community health worker. Sometimes they think we do the same type of thing, but I just try to educate them on our role. (CHW)

A lack of visibility and integration of CHWs within the clinical environment limited meaningful interactions between clinicians and CHWs to ensure a closed loop process.

I don’t even know where the new community health worker sits. I know who she is, but I don’t know where she is, so I think it feels a little bit distant so it’s a little bit harder to connect. So, when you put the referral in, you just hope that something happens. And then I just see the notes come in and see they got connected, because I forget about it at that point, so you hope it works but you don’t really know. (Clinician)

Despite strong support for the CHW program, clinicians expressed skepticism on the social services offered. Clinicians described time constraints during patient visits resulting in CHW referrals being made without the clinician having discussed the CHW’s role with the patient. This led to confusion on the patient’s end about the purpose of the CHW referral. Clinicians expressed concern about literacy level and limited language options for the HRSN screening tool. CHW program staff reported not being included in meetings with site leadership prior to CHW deployment, resulting in CHWs being sent to sites where HRSN screening had not yet started. Clinician knowledge about the CHWI varied, creating disruptions in referral workflows.

Inner Setting Domain

In this study, the inner setting includes factors related to the health system and ambulatory care sites, including communication, available resources, and culture. Several facilitators and barriers were identified within the inner setting. A major facilitator was the empowerment of CHWs who reported feeling equipped with the necessary tools to perform their roles effectively.

I have everything I need. I have a computer where I can research if they need anything. The office space is perfect for my one-on-ones when my patients come into the office. (CHW)

CHWs who took the initiative to build relationships with clinicians reported receiving more referrals, underscoring the importance of ongoing interaction between clinicians and CHWs. Successful teams demonstrated that well-established workflows were crucial for integrating CHWs into clinical practice. Clinical teams with prior experience in CHW integration were better able to adapt and maintain effective workflows. Integration was especially effective when CHWI program staff met with clinicians, leadership, and administrative staff prior to deploying CHWs to the site. Leadership and clinician buy-in was crucial for information to be shared across clinical teams. Regular reinforcement of incorporating CHWs into patient plans through teaching sessions between attending physicians and residents was also important.

Although CHWs could effectively address incorrect clinician referrals through ongoing clinician education, a power dynamic inhibited CHWs from speaking up when errors in referrals occurred. In some cases, lack of a relationship between CHWs and clinicians further impacted the ability to communicate.

An outgoing CHW that is very willing to communicate with providers on a one-on-one level, and facilitate actual meetings, really results in breaking down a lot of barriers. And the reason that I say that is because there is a power dynamic that exists. So, it’s very, very difficult sometimes for a CHW to be able to share certain things or request certain things from doctors without being super nervous. (Program Staff)

Clinicians reported not having time to follow up on CHW referrals. High staff turnover disrupted communication and referral workflows, with clinicians admitting that they often skipped monthly CHWI clinician meetings where updates were shared resulting in poor communication on role delineation. Program staff noted that initiating change was challenging, especially in environments with established protocols and clinicians who perceive the screening as additional work with an already full schedule. Clinicians expressed feeling overwhelmed and lacked the capacity to ensure that HRSN screenings were completed before patient visits.

The reality is, more and more gets put on our shoulders. But nobody’s ever given us more time to do any of it, or more, you know more ability, more, system changes to actually help us focus on these things. (Clinician)

Implementation Process Domain

The implementation process domain captures the strategies and activities used to implement the innovation. Increased CHW visibility at clinical sites was identified as a key facilitator, enabling quick “warm handoffs” between clinicians and CHWs. The role of clinicians during patient visits was crucial in facilitating CHW referrals. When clinicians thoroughly explained the CHW’s role, patients were more likely to accept referrals. Setting appropriate expectations during these discussions was critical for patient buy-in.

Patients trust their providers, so if the provider is more open to saying, ’Hey, you’re going to meet the CHW, they will help you.’ And they are aware of the scope of practice, it would be a much better outcome. (Program Staff)

Program staff observed that CHW referrals improved when CHWs actively advocated for themselves when receiving recurrent inappropriate referrals and communicating with clinicians to clarify their role. Having a flexible process for patients to meet with CHWs was crucial. For example, being able to stack clinician and CHW appointments together was viewed favorably to allow patients to meet with CHWs in person.

Significant barriers were identified in the implementation process domain. A common issue reported was the lag time between when a CHW referral was placed in the EHR and when the CHW followed up with the patient. Participants reported that unclear expectations about what CHWs could provide led to patient discouragement and frustration, likely contributing to declined referrals. CHWs worried that some patients believed that their need could be resolved immediately, but many HRSNs require multiple steps and time to resolve.

They’re hoping that I’m the person that’s gonna help them solve all their problems. (CHW)

CHWs expressed frustration with their rigid work schedules, which often mirrored those of their patients, limiting their ability to meet patients outside of standard working hours. Certain patient populations, such as migrant communities, were more difficult to reach due to lack of phone or email addresses. The overwhelming amount of paperwork patients receive during clinical visits led to lack of screening or missing documentation for completed screenings, resulting in missed opportunities for patients with HRSNs to be referred to CHWs.

Discussion

This study sought to identify the facilitators and barriers to implementing a HRSN screening and referral to CHW program within a large urban health system. Understanding these factors is crucial for developing a replicable framework that other health systems can adopt to effectively screen for and address HRSNs. Our findings identified several critical barriers, including confusion around CHW roles, hierarchical power dynamics in healthcare, gaps in clinician communication, and disillusionment with social services. Key facilitators included strong leadership buy-in and adequate preparation of clinical sites. Addressing these barriers and leveraging facilitators can significantly enhance CHW integration and program success.

Clarifying CHW Roles

Our findings, consistent with previous literature, revealed confusion surrounding the roles of CHWs and their value in the healthcare system.^13,26,37 A common misunderstanding among both patients and clinicians relates to the role of a CHW versus a social worker. A program in Michigan that paired CHWs with nurses and social workers reported similar challenges.³⁸ In response, the team developed a CHW role document that improved team integration and collaboration.³⁹ Establishing role clarity ensures CHWs can effectively complement the work of other team members.

Hierarchical Power Dynamics in Healthcare

Hierarchical power dynamics in healthcare settings can negatively impact CHWs’ integration within clinical teams and interactions with clinicians.⁴⁰ CHWs often excel in “soft skills”—such as empathy, communication, and adaptability—while healthcare systems tend to value and prioritize “hard skills” such as technical expertise and higher education credentials.⁴¹ This imbalance may undervalue the unique contributions of CHWs, creating challenges for effective teamwork and collaboration. The strength of CHWs lies within their shared life experiences with the community members they serve, which fosters trust with patients.¹⁵ Health systems can empower CHWs to further cultivate these skills rather than comparing them with the same metrics used to value clinical providers. This may require developing different objective methods in measuring the efficacy and success of CHWs. Addressing these power dynamics and recognizing the critical role of interpersonal skills is crucial for fostering a more inclusive and effective healthcare environment.

Leadership Buy-In and Preparation of Clinical Sites as a Catalyst for Success

Strong leadership buy-in emerged as a crucial facilitator for CHW program success. Effective leadership fosters an environment where care team members clearly understand the role of CHWs and how to collaborate with them.⁴⁰ Success in achieving shared objectives requires strong leadership.⁴² Another study highlighted the significant role that supportive leadership plays in ensuring the successful implementation of CHW programs.²⁶

One way for leadership to support CHW integration is through adequate preparation of both clinical teams and patients. Clinical teams can initiate screenings and lay the groundwork before CHWs are deployed, ensuring a smoother integration process. Patients also require preparation for CHWs. CHWs express greater readiness for integration into clinical settings than patients do in utilizing CHWs.⁴³ CHW-led outreach programs have proven effective in enhancing patient-CHW relationships, fostering trust, and promoting a better understanding of CHW services.^44,45 Building these relationships is key to improving patient engagement and program success.

Although many program staff and CHWs stated that a clinician champion is integral to a functioning team, previous research within this health system found little difference in referral rates at sites with or without clinician champions, however engagement levels of clinical champions was not examined.²⁰ More research is needed to understand the role and level of engagement required by clinician champions to improve implementation.

Gaps in Clinician Communication and Attendance

Low clinician attendance at team huddles, where CHW program updates are discussed, further exacerbated communication breakdowns. CHWs expressed frustration about attending team meetings to share program updates, but no clinician was present. Studies have demonstrated that teams with higher engagement, including consistent clinician attendance at meetings, have more successful program implementation.⁴⁶

Disillusionment With Social Services

Participants expressed disillusionment with the social services available to address HRSNs. This sentiment is consistent with studies that found that community members feel hopeless about the lack of resources to adequately address their HRSNs.⁴⁷ The process of seeking social services can feel dehumanizing when resource-limited programs prioritize cost savings over the holistic needs of vulnerable populations.⁴⁸ Importantly, CHWs—who often share similar backgrounds and life experiences with the communities they serve—are uniquely positioned to build rapport and foster a sense of camaraderie, offering a more humanizing approach to addressing HRSNs.⁴⁸

Study Limitations and Future Research

Our study is the first study to explore clinician and CHW perspectives on a CHW HRSNs screening and referral program in a large health system. This study had some limitations. First, the small sample size and inclusion of only 2 clinical teams limit the generalizability of our findings. However, these interviews provide valuable and broad preliminary insights on barriers and facilitators to CHW referrals and screenings that are applicable to most health systems and can guide improvements. Another limitation was potential selection bias, as the clinicians, program staff, and CHWs who participated may have been more actively engaged with the program, leading to an overrepresentation of certain perspectives. Additionally, as with most qualitative research, the absence of objective, quantitative data may limit the breadth and confidence of conclusions that can be drawn.

Future research should test targeted interventions addressing the barriers identified in this study. Testing implementation strategies to reduce referral lag times, enhance clinician engagement, and leverage technology could improve the efficiency and effectiveness of CHW referrals, thereby connecting more patients with unmet HRSNs to CHWs and social services. Moreover, further research should explore specific interventions aimed at strengthening relationships between CHWs and clinical teams. Overall, this qualitative study contributes to the growing body of research focused on integrating CHWs into health systems to better address HRSNs in historically underserved communities.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251334210 – Supplemental material for Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx

Supplemental material, sj-docx-1-jpc-10.1177_21501319251334210 for Barriers and Facilitators to the Implementation of a Health-Related Social Needs Screening and Referral Intervention in the Bronx by Priya Elizabeth George, Jessica Haughton, Renee Whiskey, Samantha Levano, Hemen Muleta and Kevin P. Fiori in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We thank the Community Health Workers and program staff of the Community Health Worker Institute at Montefiore Einstein and healthcare providers from Montefiore Medical Group who participated in this study.

ORCID iDs

Priya Elizabeth George

Jessica Haughton

Hemen Muleta

Kevin P. Fiori

Ethical Considerations

The Albert Einstein College of Medicine and Montefiore Medical Center’s Office of Human Research Affairs institutional review board approved the study protocol (IRB 2017-8434; reference 107930; date: November 2, 2023).

Consent to Participate

All participants provided informed consent before participating.

Consent for Publication

Not applicable.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this work was provided by the New York Health Foundation.

Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

Data consisted of qualitative interviews which will not be shared online due to anonymity.

Supplemental Material

Supplemental material for this article is available online.

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