Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Peer Counselor, Telephone Support, Educational Material, PROVIDER/PRACTICE, Community Health Workers (CHWs)

Intervention Description: To assess whether a theory-based, community health worker–delivered intervention for household smokers will lead to reduced secondhand smoke exposure to children in Chinese families.

Intervention Results: Of the 318 families randomized, 98 (60%) of 164 intervention group and 82 (53%) of 154 of controls completed 6-month follow-up assessment. At the 6-month follow-up, 62% of intervention and 45% of comparison group households adopted complete smoking restrictions at home (P = .022); total exposure (mean number of cigarettes per week ± standard deviation) from all smokers at home in the past 7 days was significantly lower among children in the intervention (3.29 ± 9.06) than the comparison (7.41 ± 14.63) group (P = .021); and mean urine cotinine level (ng/mL) was significantly lower in the intervention (0.030 ± .065) than the comparison (0.087 ± .027) group, P < .001). Participants rating of the overall usefulness of the intervention was 4.8 + 0.8 (1 standard deviation) on the 5 point scale (1 not at all and 5 = very useful). Conclusions

Conclusion: The findings of this very first study in China showed that smoking hygiene intervention was effective in reducing children's exposure to secondhand smoke. These findings have implications for the development of primary health care–based secondhand smoke exposure reduction and family oriented smoking cessation interventions as China moves toward a smoke-free society.

Study Design: RCT

Setting: Community (households)

Population of Focus: Smoking parents or caregivers who had a child aged 5 years or younger

Data Source: Health center records and parent selfreport.

Sample Size: 318 families

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Community Health Workers (CHWs), Outreach (Provider), PATIENT/CONSUMER, Motivational Interviewing, Telephone Support, Home Visits

Intervention Description: To evaluate the effectiveness of a lay delivered intervention to reduce Latino children’s exposure to environmental tobacco smoke (ETS). The a priori hypothesis was that children living in households that were in the intervention group would have lower exposure over time than measurement only controls.

Intervention Results: There were no significant condition-by-time interactions. Significant or near significant time main effects were seen for children’s hair cotinine and parent’s report of exposure.

Conclusion: Applying a lay promotora model to deliver the behavioural problem solving intervention unfortunately was not effective. A likely explanation relates to the difficulty of delivering a relatively complex intervention by lay women untrained in behaviour change theory and research methods.

Study Design: Two group, randomized control trial

Setting: Community (home)

Population of Focus: Latino children

Data Source: Recruited from community organizations and venues such as Head Start Programs and cultural fairs

Sample Size: 143 Latino parents of children aged 1 to 9 who reported smoking at least 6 cigarettes a week

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Community-Based Group Education, Community Health Workers (CHWs), Outreach (caregiver),

Intervention Description: The study describes a community-specific and culturally coherent approach to youth mental health services, emphasizing culturally relevant adjustments in the delivery of youth mental wellness services and related community wellness initiatives, with a focus on connections to culture and traditional skills, and strengthening support systems to improve access to mainstream mental healthcare when needed.

Intervention Results: The study highlights the adaptation of the ACCESS Open Minds framework to Inuit paradigms in Ulukhaktok and its potential as a sustainable prototype for delivering youth mental health services in Indigenous communities.

Conclusion: The conclusion emphasizes the need for easier access to specialized mental health services when needed in Indigenous communities.

Study Design: Community-specific and culturally coherent approach to youth mental health services

Setting: Ulukhaktok, Northwest Territories, Canada

Population of Focus: Indigenous youth in the Ulukhaktok community

Sample Size: Not explicitly mentioned in the provided abstract

Age Range: Age range: Primarily focused on youth under the age of 25, with a specific emphasis on adolescents

Intervention Components (click on component to see a list of all articles that use that intervention): Multicomponent Approach, Funding Support, Community Health Workers (CHWs),

Intervention Description: This multi-component intervention included patient education about health conditions (hypertension, gestational diabetes, and depression), important health behaviors (nutrition and exercise), and common postpartum symptoms; taught self-management skills; enhanced social support; and connected patients with community resources and health care services, including transportation needs. The intervention also addressed specific psychosocial needs of enrollees. A payment reform component included a cost-sharing arrangement between the health care system and the Medicaid payer to cover costs related to employing a social worker and community health worker, and financial incentives for completed postpartum visits.

Intervention Results: Compared with women in the control group, program participants had higher rates of postpartum visits in the HEDIS-defined time period (66.9% vs 56.0%; P < .001) and higher rates of all postpartum outpatient or gynecologic care up to 90 days after delivery (90.2% vs 83.4%; P= .002). Similarly, program participants were more likely to be enrolled with the Medicaid plan than mothers in the matched comparison group at six months after delivery (79.1% [400/506] vs 73.3% [742/1012]; P= .015) and at one year after delivery (71.0% [359/506] vs 66.3% [671/1012]; P= .067), although this was not statistically significant at one year after delivery.

Conclusion: This novel partnership between a health care system and a Medicaid payer increased postpartum visits among high-risk, low-income mothers. The follow-up rate was higher for visits that occurred within 90 days after delivery, a period consistent with current recommendations for postpartum care from the American College of Obstetricians and Gynecologists. This is one of few initiatives that have integrated health care systems, payers, physicians, and social workers to address access to care and social determinants of health for underserved women.

Study Design: Propensity scoring of Medicaid claims data from 2014 to 2017 was used to compare timely postpartum visits for mothers enrolled in the intervention program versus a similar group of mothers enrolled in the same Medicaid plan who gave birth in 2015 and 2016.

Setting: Mount Sinai Hospital, a large tertiary hospital in New York City

Population of Focus: Women insured by Healthfirst who delivered between April 2015 and October 16 who spoke Spanish or English and had at least 1 of the following: gestational diabetes, hypertension, positive screen for depression, late registration for prenatal care (> 20 weeks), or residence in neighborhoods considered at high risk for diabetes or hypertension.

Sample Size: 506

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Community Health Workers (CHWs), PATIENT/CONSUMER, Home Visits, Educational Material, Other Person-to-Person Education, Peer Counselor, Motivational Interviewing, CAREGIVER, Home Visit (caregiver), Education/Training (caregiver), Educational Material (caregiver), Motivational Interviewing/Counseling

Intervention Description: We assessed the effectiveness of a community health worker intervention focused on reducing exposure to indoor asthma triggers.

Intervention Results: The high-intensity group improved significantly more than the low-intensity group in its pediatric asthma caregiver quality-of-life score (P=.005) and asthma-related urgent health services use (P=.026). Asthma symptom days declined more in the high-intensity group, although the across-group difference did not reach statistical significance (P= .138). Participant actions to reduce triggers generally increased in the high-intensity group. The projected 4-year net savings per participant among the high-intensity group relative to the low-intensity group were $189–$721.

Conclusion: Community health workers reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score. Improvement was greater with a higher-intensity intervention.

Study Design: RCT

Setting: Community (home)

Population of Focus: Families in low-income households with children with asthma

Data Source: In-home interviewing, dust sample and standardized home inspection

Sample Size: 274 randomized participants

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services, Individual Supports, Community Health Workers (CHWs),

Intervention Description: conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital).

Intervention Results: Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group.

Conclusion: findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.

Study Design: Crossectional Cohort Study

Setting: Clinical

Population of Focus: Black birthing people

Sample Size: 806

Age Range: 24-36

Intervention Components (click on component to see a list of all articles that use that intervention): Access, Community Health Workers (CHWs), Mobile Programs

Intervention Description: The authors created extending Maternal Care After Pregnancy (eMCAP), a community-based program, to address health care disparities and enhance access to care for the 12 months after birth. The team also evaluated the ability of Z codes (ICD-10 codes for social determinants of health) to identify patients with health-related social needs. The program is a multidisciplinary effort of nurses, nurse home visitors, physicians, advanced practice providers (APRNs [advanced practice registered nurses]), community health workers (CHWs), social services, behavioral health teams, and pharmacists working within a specially designed electronic health registry linked to existing electronic medical records and an obstetric quality database.

Intervention Results: The eMCAP program demonstrated improvement in attendance and quality of postpartum care for women living in underserved areas with chronic hypertenion (CHTN) and diabetes mellitus (DM). Compared to matched controls who were provided standard referrals, follow-up postpartum attendance for eMCAP women with CHTN was significantly better at 2 weeks and 1, 3, 6, 9, and 12 months (all p < 0.001). Similarly, eMCAP women with DM had significantly better follow-up at 2 weeks (p = 0.04), 1 month (p = 0.002), and 3 months (p = 0.049), resulting in HbA1c values for DM being significantly lower (p < 0.05) throughout the postpartum period.

Conclusion: The postpartum period represents a critical opportunity to understand and improve short- and long-term health with various platforms suggested to combat this crisis, but the roles of access to care, community-based support, and electronic health management systems remain unknown. We offer our experiences from eMCAP as an opportunity for further study in other health care settings. The findings of improved health care outcomes are key measures important to improving maternal morbidity and mortality across the United States.

Study Design: Observational study

Setting: Parkland health system in Dallas

Population of Focus: Predominantly Black and Hispanic women

Sample Size: 1,479 enrolled women

Age Range: Reproductive age

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Workers (CHWs), Home Visits,

Intervention Description: The Baby Love program, administered by the Social Work Division of the University of Rochester Strong Memorial Hospital, pairs licensed, master’s-prepared social workers with community health workers (CHWs) to address barriers to health for high-risk pregnant and parenting women and infants as part of an interdisciplinary, perinatal health care team. The program serves participants by (1) increasing linkage with health and community support services, (2) educating participants on perinatal- and parenting-related topics along with stress-reduction strategies, and (3) providing support and advocacy for participants. The CHW serves as the primary Baby Love service provider, completing regular home visits and forming supportive relationships throughout the course of a women’s pregnancy and for one year postpartum. To facilitate integrated care, all interventions are documented in the participant’s medical record.CHWs are trained based on the Family Development Credential Program, a strengths-based approach of partnership between the family and CHW that is focused on achieving identified service goals.

Intervention Results: During the study period, Baby Love participants had fewer adverse outcomes than did nonparticipants, including lower rates of preterm birth. Neonatal intensive care unit (NICU) admission rates were 16% among participants compared with 21% among nonparticipants. The odds of NICU admission, preterm birth, and low birth weight were all lower among Baby Love participants than nonparticipants, whereas the odds of attending a postpartum visit within 60 days and attending at least four well-child visits within six months after births were higher.

Conclusion: The societal imperative to improve perinatal outcomes continues to pose a public health challenge. Well-structured CHW-supported home-visiting programs are a promising tool to more fully address the needs of a broader population of diverse and socioeconomically disadvantaged pregnant women. The Baby Love program’s effectiveness at improving perinatal outcomes and addressing social determinants of health from its integrated placement within the health delivery system positions this program as a valuable contributor to a fully integrated care delivery system

Study Design: Retrospective cohort study

Setting: Social Work Division of the University of Rochester Strong Memorial Hospital

Population of Focus: At-risk pregnant women

Sample Size: 353 enrolled with Baby Love;102 in comparison group

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Community Health Workers (CHWs),

Intervention Description: The Coordination of Healthcare for Complex Kids (CHECK) program is a healthcare innovation project designed as a quality improvement project to provide comprehensive care coordination in children insured by Illinois Medicaid with chronic disease. The CHECK model consisted of community health workers (CHWs) supported by pediatricians, subspecialists, behavioral health providers, and legal experts. All were focused on helping families navigate the complex healthcare system. This design provides an opportunity to investigate the effectiveness of CHWs integrated with the healthcare system (29–32).

Intervention Results: Children engaged in CHECK were more likely to be female (p=.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p=.027) but did not differ by the second year (p=.948). At baseline, 68.1% of the cohort had at least one ED visit 12 months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p=.010) and 40% more likely to have a controller.

Conclusion: CHECK program receipt was associated with improved healthcare utilization and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Study Design: The study design is a retrospective analysis of the Coordination of Healthcare for Complex Kids (CHECK) program, which ran from December 1, 2014, through August 31, 2017. The study used healthcare utilization claims data from Illinois Medicaid to evaluate the impact of the CHECK program on school absence, healthcare utilization, asthma prescriptions, and cost in low-income school-aged children with asthma. The study also assessed whether the amount of community health worker (CHW) services received was associated with changes in outcomes.

Setting: The study was conducted in Chicagoland, which includes vulnerable communities in Chicago, Illinois. The CHECK program was housed at the University of Illinois at Chicago

Population of Focus: he target audience for the study includes healthcare professionals, policymakers, researchers, and organizations involved in pediatric asthma care coordination, health disparities, and health equity initiatives. The study's findings and lessons learned are relevant to those interested in improving pediatric asthma outcomes and addressing health disparities in vulnerable populations.

Sample Size: The sample size of the study included a total of 2,668 children with asthma who were enrolled in the CHECK program. Among them, 1,701 children were classified as having a medium baseline risk, and 185 children had a high baseline risk. The sample size reflects a diverse cohort of varying severity and control of asthma, including children with other chronic conditions.

Age Range: The study included patients who were 0-25 years old and insured by Illinois Medicaid. However, for this analysis, the CHECK cohort was limited to school-aged children (K-12) attending Chicago Public Schools

Intervention Components (click on component to see a list of all articles that use that intervention): Collaboration with Local Agencies (Health Care Provider/Practice), Community Health Workers (CHWs), Patient-Centered Medical Home,

Intervention Description: The intervention involved comparing outcomes for youth in crisis who received a crisis evaluation in a primary care behavioral health (PCBH) setting to those presenting to the emergency department at the main hospital campus.

Intervention Results: The results indicated that youth evaluated in the PCBH setting were more likely to receive a psychiatric admission, had a shorter latency to the next behavioral health appointment, and had higher rates of completing at least one visit in the year following the evaluation.

Conclusion: Opportunities for future research on cost-effectiveness of care and continuous improvement aligned with quadruple aim outcomes are discussed. Overall, this study is among few others investigating the potential for pediatric integrated care models to contribute to youth suicide prevention and the study demonstrated promising increases in access and engagement with timely behavioral health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Study Design: The study utilized a retrospective cohort study design.

Setting: Large, predominantly rural health system, comparing outcomes for youth who received a crisis evaluation in a primary care behavioral health (PCBH) setting to those presenting to the emergency department at the main hospital campus.

Population of Focus: The target audience includes healthcare providers, policymakers, and researchers interested in pediatric integrated care and youth mental health services.

Sample Size: The study compared outcomes for 171 youth who received a crisis evaluation in a PCBH setting to 171 youth presenting to the emergency department.

Age Range: The study focused on adolescents and young adults, as it discussed crisis evaluations for individuals aged 10–24 who were at risk for suicide

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Workers (CHWs), Educational Material, Training, Screening in Nontraditional Settings

Intervention Description: The intervention described in the article to increase postpartum depression (PPD) screening is the implementation of a community health worker (CHW) program . The CHWs were trained to assist providers with PPD screening and behavioral health referrals by addressing patient barriers to care. The CHWs also provided education to patients and families about PPD and the importance of screening. The CHWs were available to assist patients during their well-child visits and provided follow-up phone calls to patients who screened positive for PPD.

Intervention Results: The study found that the implementation of a community health worker (CHW) program was effective in increasing postpartum depression (PPD) screening rates in a pediatric patient-centered medical home (PCMH) that primarily serves a Latinx immigrant population. The study found that the overall screening rate increased from 45% to 66% after the implementation of the CHW program . The study also found that the rate of patients referred after positive screenings increased from 9% to 22% following project implementation . The study concludes that CHWs can assist providers with PPD screening and behavioral health referrals by addressing patient barriers to care and that future studies focusing on the referral process for PPD treatment and resources for minority populations are needed to assess the impact of screening on maternal and infant clinical outcomes

Conclusion: Postpartum depression is a serious problem that affects many new mothers and often goes unrecognized, with even higher prevalence among minority populations, specifically immigrant mothers. Pediatric providers caring for infants and mothers must prioritize screening for PPD to improve diagnostic rates and ensure effective referrals and treatment protocols are in place. This project demonstrates how CHWs can assist providers with PPD screening and behavioral health referrals by addressing patient barriers to care. Future studies focusing on the referral process for PPD treatment and resources for minority populations, are needed to assess the impact of screening on maternal and infant clinical outcomes.

Study Design: The study design is a pre- and post-intervention study . The study evaluated the effectiveness of implementing a community health worker (CHW) intervention to improve postpartum depression (PPD) screening and referral rates in two South Carolina patient-centered medical homes that primarily provide care to low-income Latinx populations . The study collected pre- and post-implementation data by reviewing current procedural terminology (CPT) billing codes and examining patient charts

Setting: Pediatric clinic that serves a diverse population of patients, including Latinx and immigrant mothers two South Carolina patient-centered medical homes that primarily provide care to low-income Latinx populations

Population of Focus: However, it is likely that the target audience includes healthcare providers, policymakers, and researchers who are interested in improving postpartum depression screening and referral rates in diverse populations, particularly Latinx and immigrant mothers. The study provides insights into the effectiveness of utilizing community health workers (CHWs) to improve PPD screening and referral rates in low-income Latinx populations

Sample Size: he sample size for the study is 552 patients . This sample size was used to evaluate the effectiveness of the interventions implemented in two South Carolina patient-centered medical homes that primarily provide care to low-income Latinx populations

Age Range: The study does not focus on a specific age group. However, the sample population includes newborns and children up to 6 months of age who were seen at 1 month and 6-month well-child visit

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Workers (CHWs), Prenatal Care Access, Care Coordination,

Intervention Description: The intervention being evaluated in the study is the Health Start Program (HSP) in Arizona. The HSP is a community health worker (CHW) home visiting perinatal support program. CHWs are required to complete 12 hours of continuing education per year . The HSP aims to provide support to at-risk, racially and ethnically diverse, rural, and urban mothers and children in Arizona. The program focuses on improving maternal and child health outcomes by providing various forms of support, including prenatal care, newborn health, and child health up to 5 years of age. The program involves home visits and aims to address the significant challenges and barriers to obtaining healthcare services faced by under-resourced women in Arizona. The specific details of the intervention activities and content are not explicitly outlined in the study protocol

Intervention Results: It primarily focuses on the evaluation protocol, data sources, outcome measures, and the methodology used for assessing maternal and child health outcomes using administrative data.

Conclusion: The study aims to meet the federal Home Visiting Evidence of Effectiveness (HomVEE) standard for evidence-based effectiveness. The study will use a matched comparison group design that meets the published standard for HomVEE's moderate rating. The study will evaluate the impact of the HSP on multiple maternal, infant, and child health outcomes using a combination of four data source

Study Design: The study design is a retrospective, propensity score-matched observational study. The study uses a matched comparison group design that meets the published standard for Home Visiting Evidence of Effectiveness (HomVEE) moderate rating. The study aims to evaluate the impact of the Health Start Program (HSP) on multiple maternal, infant, and child health outcomes. The study uses a combination of four data sources: the HSP database, Vital Records Birth Data, Hospital Discharge Data, and Arizona State Immunization Information System. The study employs propensity score matching (PSM) to create a synthetic comparison group to observe the "counterfactual" to HSP participation, that is, what would have happened in the absence of the program. The study will compare outcomes between HSP mothers and those matched to them by the propensity score

Setting: The setting for this study is the state of Arizona in the United States. Arizona is the sixth largest state in the US, with a population of 6.8 million people. The state is unique in its racial and ethnic diversity, with a higher proportion of Latino and American Indian residents compared to the national average. Additionally, nearly a quarter of the population lives in rural areas, where poverty rates are almost double that of the national poverty rate. The Health Start Program (HSP) is a statewide program that employs community health workers (CHWs) in 14 distinct Arizona counties to engage at-risk, low-income mothers and improve maternal and child outcomes .

Population of Focus: The target audience for the Health Start Program (HSP) in Arizona includes at-risk, low-income, and racially and ethnically diverse pregnant women and their families. The program aims to engage this specific demographic to improve maternal and child outcomes by providing support, education, and advocacy through the use of community health workers (CHWs) who reflect the ethnic, cultural, and socioeconomic characteristics of the communities they serve. The HSP is designed to address the needs of under-resourced women and families who may face significant challenges and barriers to obtaining healthcare services, particularly prenatal care

Sample Size: However, the protocol does mention that the analytic population is of sufficient size to detect meaningful program effects from low-frequency events, including preterm births, low and very low birth weights, maternal morbidity, and differences in immunization and hospitalization rates over a relatively long period. The study also notes that lack of statistical power is not a significant issue for this project, despite the respective sizes of the intervention and comparison populations

Age Range: The study focuses on maternal and child health outcomes within the context of the Health Start Program (HSP) in Arizona. While the specific age range of the children included in the study is not explicitly mentioned, the outcomes evaluated are related to prenatal care, newborn health, and child health up to 5 years of age. Therefore, the study likely encompasses maternal and child health outcomes from prenatal care initiation through early childhood, covering a broad age range from prenatal to early childhood stages

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Community Health Workers (CHWs), EMR Reminder,

Intervention Description: The intervention aimed at optimizing community-based referrals in primary care using Quality Improvement (QI) methodology. The intervention involved several components, including: Dedicating space for Community Health Workers (CHWs) near providers. Creating electronic CHW schedules and warm handoff blocks, Improving communication with providers using email and huddle reminders, Posting informative signs in exam rooms, Co-locating services with medical providers, Creating scheduled warm handoff blocks. Improving leadership involvement and communication with providers. These interventions align with a discernible strategy of optimizing workflows to increase warm handoffs with CHWs, with a focus on co-locating services, creating scheduled warm handoff blocks, and improving leadership involvement and communication with providers. The article presents a study that analyzes a multicomponent intervention aimed at optimizing community-based referrals in primary care using QI methodology. The intervention involved multiple strategies and components to improve the warm handoff rate between families with unmet social needs and CHWs, demonstrating a comprehensive approach to addressing social determinants of health in a primary care setting

Intervention Results: The CHW warm handoff rate increased two-fold from a monthly median of 11% to 24% in the intervention period. The number of social needs screenings completed and CHW referrals increased during the intervention period. Of all patients screened in the intervention period, 8.4% were referred to a CHW, significantly higher than the referral rate in the baseline period. Of all referrals made in the intervention period, 22% had a warm handoff, also significantly higher than the warm handoff rate in the baseline period. The Ages and Stages Questionnaire Third Edition (ASQ-3) screening rate at the 12-month well-baby visit showed an increase from a baseline median rate of 83% to 92% in the intervention period . These results indicate the effectiveness of the QI intervention in increasing the CHW warm handoff rate and improving the social needs screening and referral process in the primary care setting.

Conclusion: The results illustrate that QI methods can be used to optimize workflows to increase warm handoffs with CHWs. This is important as health centers work to improve their social needs screening and referral programs.

Study Design: The study design used in the article is a Quality Improvement (QI) methodology. The authors used the Model for Improvement as the QI framework to increase Community Health Worker (CHW) warm handoffs. They conducted several Plan, Do, Study, Act (PDSA) cycles, which is a key quality improvement model used for rapid change testing and process improvement. The study analyzed the impact of the intervention on process measures, outcome measures, and balancing measures

Setting: The study was conducted at an academic-affiliated federally qualified health center (FQHC) located in the South Bronx, New York. The FQHC has been established since 1967 and is located in congressional district 15, which is the poorest in the nation . The study was conducted in a single site, which may limit the generalizability of the findings to other healthcare settings. However, the study provides insights into the effectiveness of quality improvement methods in optimizing community-based referrals and warm handoffs in a primary care setting.

Population of Focus: The target audience for this study includes healthcare professionals, particularly those involved in primary care and community health settings. This may encompass physicians, nurses, community health workers, social workers, and other healthcare providers who are interested in improving the identification and referral of patients with unmet social needs. Additionally, individuals and organizations involved in quality improvement initiatives within healthcare settings may also find the study relevant. The findings and methodologies presented in the article are likely to be of interest to those seeking to optimize community-based referrals and warm handoffs in primary care using quality improvement methodology.

Sample Size: The article does not explicitly mention the sample size in terms of the number of patients involved in the study. However, it does provide specific data points related to the number of patients screened for social needs in both the baseline and intervention periods, as well as the number of CHW referrals placed. These data points indicate the scale of the study, but the exact sample size in terms of the number of patients is not explicitly stated.

Age Range: The article does not specify a specific age range for the patients involved in the study. However, it does mention that the screening was conducted most often by a parent or guardian prior to the medical exam at new patient visits and annual well-child visits from birth through age 21 . Therefore, it can be inferred that the study involved patients from birth through age 21.