Center for Community Health Navigation (CCHN)

Community Health Worker Programs

Pediatric Community Health Worker Program

The Pediatric Community Health Worker (CHW) program, WIN for Asthma, was developed in 2005 in partnership with local community-based organizations to support families of children with poorly managed asthma.  In 2014, this nationally recognized model expanded to Cornell also, to include children with special health care needs.  In 2018, the initiatives merged to become a single Pediatric CHW Program and also expanded to support children at risk of hearing loss as part of a grant from the Oberkotter Foundation. The program supports caregivers of children admitted to the hospital with a diagnosis of asthma and those caregivers of vulnerable children with special health care needs at NewYork-Presbyterian/Columbia University Irving Medical Center, NewYork-Presbyterian/Weill Cornell Medical Center and most recently at NewYork-Presbyterian Queens and the surrounding communities.

Bilingual and culturally sensitive pediatric CHWs are based in community-based organizations, allowing them to remain anchored in the community. They also have a strong presence in affiliated PCMHs where they provide education and support to patients and where they participate in interdisciplinary team meetings, often filling in gaps with the community based perspective.  Pediatric CHWs serve as a single point of contact for caregivers and empower them to manage their child's condition and connect them to resources in the community and the Hospital.

Caregivers who participate in this program receive comprehensive information centering on three key messages:

  • Knowing your child's condition(s)
  • Knowing how to access health care for your child
  • Keeping your child's condition(s) under control

Caregivers also receive support related to:

  • Organizing and accessing their child's medications
  • Transitioning from pediatric to adult medical care as the child gets older
  • Coordinating care and social service referrals to address competing obstacles, such as housing, educational support, immigration and employment

Since July 2016, 10 CHWs supported 229 children with special healthcare needs. Eighty-five percent of caregivers with unmet social needs were successfully connected to social service resources that address needs related to housing, food insecurity, and insurance. Nearly 60 percent of the 74 participants who completed the program reported decreased levels of distress upon discharge. In addition, to date, CHWs have conducted 481 practice education sessions with caregivers within the pediatric clinical sites.

Adult Community Health Worker Program

In January 2012, NewYork Presbyterian Hospital (NYP) and community partners developed and implemented the WIN for Diabetes program.  This program serves patients of the Ambulatory Care Network (ACN) with poorly controlled diabetes and their caregivers through community-based motivational self-management support, home visits, comprehensive diabetes education, and links to clinical and social services.

In July 2016, NewYork-Presbyterian and our community partners collaborated to develop a comprehensive program to support adults with chronic conditions, as well as their caregivers. The goals of the program are to improve participants’ health and the healthcare experience by providing culturally sensitive, peer-based community support—enabling them to better access health care, resolve questions and needs between visits in the PCMH, and address social issues that may become barriers to achieving good health and quality of life.

Bilingual CHWs deliver education and support centered on three major categories:

  • Patient navigation (knowing how to access care)
  • Medication management (adherence, knowledge, and access)
  • Social determinants (housing, food insecurity, transportation, and immigration)

CHWs support patients to meet goals related to these specific areas.

Since June 2013, 316 patients were referred to the program and 144 of them enrolled. Of those who completed the six-month program (17), 65 percent reached their medication adherence goal and 76 percent reached their patient navigation goals.

Program Contacts

Evelyn España, MHA
Program Manager, Robert Center for Community Health Navigation at NewYork-Presbyterian Brooklyn Methodist Hospital
Patient Navigator Program, Adult CHW Program
[email protected]

Henley Vargas, MSW
Program Manager, Robert Center for Community Health Navigation at NewYork-Presbyterian Queens Hospital
Patient Navigator Program, Adult CHW Program, Pediatric CHW Program
[email protected]

Kristy Medina, MPH
Program Manager, Center for Community Health Navigation at NewYork-Presbyterian/Columbia University Irving Medical Center, NewYork-Presbyterian/Weill Cornell Medical Center, NewYork-Presbyterian/Lower Manhattan Medical Center
Adult CHW Program, Pediatric CHW Program
[email protected]

Carmen Cruz
Program Lead, Center for Community Health Navigation at NewYork-Presbyterian/Columbia University Irving Medical Center, NewYork-Presbyterian/Weill Cornell Medical Center
Adult CHW Program
[email protected]