April 10, 2020

Community-based Health Centers Critical to Bronx Wellness


Last week UNHP published a blog looking at the well-documented long-standing income, racial and ethnic disparities, as well as health issues in the Bronx, which led to a disproportionate number of COVID-19 cases in the borough. Entitled Bronx Reality before COVID is Manifesting Devastating and Deadly Consequences, the blog included the work of community-based health programs to address the types of chronic illnesses, like diabetes and hypertension that make Bronx residents especially vulnerable to serious consequences from the virus. In the post, we featured a video interview with Dr. Vanessa Salcedo on Bronxnet and the response of Union Community Health Center during the peak of Bronx COVID cases as well as part of an interview with Bronx Community Health Network.

UNHP has partnered with the Bronx Community Health Network (BCHN) for a number of years; connecting our program users with their medical care and programs, especially low-cost health insurance and medical care for those without insurance. We wanted to share more of an email interview we had with BCHN in this post. Eleanor Larrier, MPA, CEO, Tashi Chodon, BSN, MPH, Director of Programs, and Jay Izes, MD, Chief Medical Officer answered questions about their work and Covid-19 response.

Bronx residents with chronic illnesses like diabetes, asthma and hypertension have suffered serious health consequences from COVID-19. How has BCHN been effective in treating some of the chronic illnesses so prevalent in the Bronx?

BCHN’s community-based health and wellness programs are rooted in the strategies employed by pioneers of the community health center movement that began in 1965, funded by President Johnson’s War on Poverty. They recognized the importance of including community residents who understand the culture and mores of their neighborhoods in planning and defining how preventive and primary care should be delivered. They understood the importance of addressing what’s now called social determinants of health (SDH). Doctors wrote prescriptions not only for medication but for food, housing repair, sanitation. Studies show that when underlying socio-economic barriers—housing, employment, employment and career training, child care—are addressed, people living with chronic diseases like asthma, hypertension, diabetes, obesity and HIV/AIDS are better able to manage their illnesses and lead healthy, productive lives. BCHN’s partnership with UNHP is an important and valued resource.

How is your care different from other medical care?

Facility-based health care appropriately focuses on diagnosing and treating illness. However, there is growing recognition of the importance and value of incorporating outreach strategies that engage individuals and families in face-to-face community and in-home encounters in improving patient care quality, outcomes and reducing costs. BCHN has a foot in both camps. We are out in the community and in our partner health centers linking patients directly to the social support services they need. When their other issues are met, patients can focus more on their health leading to high compliance rates and better health.

How did BCHN deal with COVID-19? Were you able to see patients – if not how did you treat them? UNHP had to discontinue our face-to-face work and converted to phone outreach – many of the people we work with do not have access to the internet or smartphones.

BCHN’s experience is quite similar to UNHP’s. BCHN continues to promote health and wellness in the underserved Bronx community and converted all in-person work to telephonic and social medial outreach. Our community outreach specialists shifted to a work from home model, connecting with patients by phone and offering virtual workshops via social media and Zoom.

Our network health centers moved to a mostly telehealth approach in March, and are preparing to re-open in the near future.

In response to the increasing unmet social determinants of health (SDH) needs in the Bronx community, BCHN followed up with 983 Montefiore patients between March and April. As of April this year, we have successfully referred 43% (687) of the 1743 referrals that our CHWs followed up on, and 41% of these patients have reported progress made in meeting their SDH needs. Food insecurity, housing application assistance and poor housing quality are the most common needs we have been seeing during this outbreak.

To address the rising unmet food insecurity in the underserved Bronx community, BCHN launched a free emergency food delivery project on May 29. We will continue to deliver groceries we receive from Montefiore Food Pantry to those eligible for the program.

Our asthma-focused CHW reached out to 661 patients diagnosed with asthma from 3/16 to 5/8 of which almost half of these patients (321) were educated on asthma self-management, proper use of medication devices and trigger remediation, assessed and helped address their unmet social needs, and alerted providers on patients who reported having COVID-19 like symptoms or being recently discharged from hospital or needing medication refill or having issues with pharmacies dispensing medications. Our CHWs also continue to reach out to patients with diabetes who have fallen out of care and help reconnect them to their primary care providers.

Bronx Community Health Network treats the whole person and their needs. This outreach van offers mobile medical services and during the COVID 19 crisis is delivering food to the homebound and health-compromised from Montefiore Hospital Food Pantry.

Moving forward what concerns does BCHN have in terms of another outbreak and better health quality for Bronx residents? What resources and support do you need to address these concerns?

Having worked out the remote and telehealth processes, we are better prepared on this front should we need to utilize them in the future.

COVID-19 exacerbated the socioeconomic health disparities which already existed in the U.S before the outbreak, especially among medically underserved and socio-economically disadvantaged Bronx populations.

We are concerned that another outbreak will wreak even more havoc on children, adolescents and adults, compromising existing and new COVID-19 physical, mental health, social and economic challenges. Our community partnerships would be even more essential in helping us to connect our clients with needed resources.

BCHN is part of the Montefiore Health system – many NYC hospitals, like Montefiore Hospital, were overwhelmed by the number of Bronx cases – any thoughts you’d like to share about that?


BCHN contracts with Montefiore and Promesa to provide primary care and related services at 21 community and school-based health centers. Our focus is on prevention and health management services out in the community. he COVID-19 pandemic hit fast and furious. Bronx hospitals, including our partners, responded to the overwhelming demands for emergency and inpatient care. We applaud all the healthcare working on the frontlines and in supporting roles for their amazing commitment and fortitude during this pandemic.

Thank you BCHN!

UNHP applauds all our healthcare workers, especially the oft-forgotten home health aides which are vital to Bronx families and seniors. One vital key to improved community health lies in effective and well-resourced community-based care and the right for everyone to access it.

UNHP has long fought for the Bronx neighborhoods we serve. We are proud to count BCHN as a partner in that effort. Decent affordable housing for neighborhood residents, appropriate private investment, fair wages, and access to healthcare are necessary to support a vibrant community. Unsurprisingly, inequalities in healthcare, income, and housing were part of what made our community particularly vulnerable to COVID-19. The only way to truly help the community recover from the pandemic is to address the long-standing inequities that have been part of the Bronx’s history. Thank you BCHN for your work to be an innovative, caring organization that is changing lives every day.