Addressing Financial Barriers to Health Care Among People Who are Low-Income and Insured in New York City, 2014-2017.

While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW-HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities.

A Cohort Review Approach Evaluating Community Health Worker Programs in New York City, 2015-2017.

The objective of this study was to describe how a cohort review approach was applied as an evaluation framework for a community health worker intervention among adult residents in 5 public housing developments in New York City in 2015-2017. The cohort review approach involved systematically monitoring participants engaged in the Harlem Health Advocacy Partners program during a given time period ("cohort") to assess individual outcomes and program performance. We monitored participation status (completed, still active, disengaged, on leave, or died) and health outcomes. In this example of a cohort review, levels of enrollment and program disengagement were higher in cohort 1 than in cohort 2. For 6-month health outcomes, the percentage of participants with hypertension who had controlled blood pressure was static in cohort 1 and improved significantly in cohort 2. The percentage of participants with diabetes who self-reported controlled hemoglobin A1c increased significantly in cohort 1 at 6-month follow-up. The cohort approach highlighted important outcome successes and identified workload challenges affecting recruitment and retention.

Harlem Health Advocacy Partners: A Local Health Department's Place-Based Community Health Worker Program.

In January 2015, the New York City Department of Health and Mental Hygiene launched Harlem Health Advocacy Partners (HHAP), a place-based initiative to demonstrate the capacity of a CHW workforce to improve the health of residents of public housing. The long-term goal of HHAP is to improve the population health of residents of public housing in East and Central Harlem and to close racial gaps in health and social outcomes. A variety of evaluation approaches have been used to assess the initiative. This paper describes the HHAP model and methods for evaluating the program.

Implementation Facilitators and Challenges of a Place-Based Intervention to Reduce Health Disparities in Harlem Through Community Activation and Mobilization.

Background: To address significant health inequities experienced by residents of public housing in East and Central Harlem compared to other New Yorkers, NYC Department of Health and Mental Health (DOHMH) collaborated with community and academic organizations and the New York City Housing Authority to develop a place-based initiative to address chronic diseases in five housing developments, including a community activation and mobilization component led by community health organizers (CHOs). Purpose: Guided by the Consolidated Framework for Implementation Research (CFIR), we evaluated the initial implementation of the community activation and mobilization component to systematically investigate factors that could influence the successful implementation of the intervention. Methods: Nineteen in-depth qualitative interviews were conducted with a purposive sample of CHOs, community members and leaders, collaborating agencies and DOHMH staff. Interviews were transcribed verbatim, and themes and codes were developed to identify theoretically important concepts of the CFIR and emergent analytic patterns. Results: Findings identified important facilitators to implementation: positive community perception of the program, CHO engagement and responsiveness to community needs, CHO norms and values and adaptability of DOHMH and CHOs to community needs. Challenges included the instability of the program in the first year, limited ability to address housing related issues, concerns about long term funding, competing community priorities, low expectations by the community for the program, time and labor intensity to build trust within the community, and the dual roles of CHOs as community advocates and DOHMH employees. Conclusions: Findings will guide future community activation and mobilization activities. The study demonstrates the value of integrating implementation science and health equity frameworks.

A Place-Based Community Health Worker Program: Feasibility and Early Outcomes, New York City, 2015.

INTRODUCTION: This study examined feasibility of a place-based community health worker (CHW) and health advocate (HA) initiative in five public housing developments selected for high chronic disease burden and described early outcomes. METHODS: This intervention was informed by a mixed-method needs assessment performed December 2014-January 2015 (representative telephone survey, n=1,663; six focus groups, n=55). Evaluation design was a non-randomized, controlled quasi-experiment. Intake and 3-month follow-up data were collected February-December 2015 (follow-up response rate, 93%) on 224 intervention and 176 comparison participants, and analyzed in 2016. All participants self-reported diagnoses of hypertension, diabetes, or asthma. The intervention consisted of chronic disease self-management and goal setting through six individual CHW-led health coaching sessions, instrumental support, and facilitated access to insurance/clinical care navigation from community-based HAs. Feasibility measures included CHW service satisfaction and successful goal setting. Preliminary outcomes included clinical measures (blood pressure, BMI); disease management behaviors and self-efficacy; and preventive behaviors (physical activity). RESULTS: At the 3-month follow-up, nearly all intervention participants reported high satisfaction with their CHW (90%) and HA (76%). Intervention participants showed significant improvements in self-reported physical activity (p=0.005) and, among hypertensive participants, self-reported routine blood pressure self-monitoring (p=0.013) compared with comparison participants. No improvements were observed in self-efficacy or clinical measures at the 3-month follow-up. CONCLUSIONS: Housing-based initiatives involving CHW and HA teams are acceptable to public housing residents and can be effectively implemented to achieve rapid improvements in physical activity and chronic disease self-management. At 3-month assessment, additional time and efforts are required to improve clinical outcomes.