Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Community Health Worker Integration Into the Health Care Team Accomplishes the Triple Aim in a Patient-Centered Medical Home: A Bronx Tale

Findley, Sally PhD; Matos, Sergio BS; Hicks, April MSW; Chang, Ji MA; Reich, Douglas MD, MPH

Journal of Ambulatory Care Management: January/March 2014 - Volume 37 - Issue 1 - p 82–91
doi: 10.1097/JAC.0000000000000011
Original Articles

Community health workers are ideally suited to the care coordination niche within the patient-centered medical home (PCMH) team, but there are few case studies detailing how to accomplish this integration. This qualitative study documents how community health workers (CHWs) were integrated into a PCMH in South Bronx, New York. Results show that integration was linked to clear definition of their care coordination role within the care team, meticulous recruitment, training and supervision by a senior CHW, shared leadership of the care management team, and documented value for money. By helping the team understand patients' backgrounds, constraints, and preferences, they helped everyone genuinely focus on the patient.

Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York (Dr Findley); Community Health Worker Network of NYC, New York (Mr Matos); True North Consulting LLC, New York (Ms Hicks); Center for Minority Health Equity, New York University, New York (Ms Chang); Department of Family Medicine, Bronx-Lebanon Hospital, Bronx, New York (Dr Reich).

Correspondence: Sally E. Findley, PhD, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B-2, New York, NY 10032 (

The authors thank the staff of the Department of Family Medicine for so generously sharing their time and knowledge, in particular, Romelia Corvacho, Maria Murphy, Paul Beach, Angeline Thomas, Janice Void, and Maryanne Jonitis. They also thank the New York State Health Foundation for its generous support and in particular Yasmine Legendre and Jacqueline Martinez Gracel, for their advice.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins