In 2005, NewYork-Presbyterian (NYP) partnered with the communities of Washington Heights and Inwood to develop the Washington Heights-Inwood Network (WIN) for Asthma - a hospital-community partnership designed to address the burden of asthma in the local community, to strengthen the existing community-wide network of care and to improve outcomes for local children with poorly controlled asthma. More »
Bilingual CHWs serve as the single point of contact for families who enroll in the year-long care coordination program. Participating families receive comprehensive asthma education, home environmental assessments, trigger reduction strategies, on-going support, and social service referrals that address competing obstacles such as housing, immigration, and employment. CHWs are based in partner community based organizations, allowing them to remain anchored in the community while also maintaining a strong presence in the hospital and 6 Patient Centered Medical Homes where they provide culturally appropriate education and support to families who require immediate assistance.
As of December 2015, CHWs have enrolled over 1300 families of children with poorly controlled asthma in the yearlong care coordination program. Among program graduates, hospitalizations decreased by 76%, emergency department (ED) visits decreased by 68%, and 95% of caregivers reported feeling able to manage their child's asthma.
In 2012, NewYork-Presbyterian (NYP) was awarded a five-year grant from the New York State Department of Health to serve as one of New York State's eight regional asthma coalitions. Washington Heights/Inwood Network Best Asthma Care for Kids (WIN-BACK) was established as an expansion of existing efforts by the WIN for Asthma program to support children with poorly controlled asthma and their families and to address the disproportionate burden of asthma in Northern Manhattan. More »
Key to the program's success has been the creation of a multi-partner community coalition. The Coalition developed a primary care provider (PCP) directory, held PACE (Physician Asthma Care Education) trainings, supported Certified Asthma Educator trainings, and launched an annual pediatric influenza vaccination clinic. In addition, they distributed much-needed asthma-related resources, such as spacers and mattress covers, to patients within Patient Centered Medical Homes (PCMH) and in the community. WIN-BACK initiatives have also led to increased use of Asthma Action Plans and severity and control documentation amongst ED providers.
The Coalition is working to engage caregivers through the development of a caregiver support group and is working closely with schools to enhance the PCMH and school connection for optimal asthma care.
The SKATE (Special Kids Achieving Their Everything) Community Health Worker (CHW) program was developed in 2015 in partnership with community based organizations to better serve families of children with special health care needs. This program serves families of children who are patients at the 5 pediatric patient centered medical homes (PCMH) in the Ambulatory Care Network at Columbia University Medical Center and Weill Cornell.
Bilingual and culturally competent CHWs serve as the single point of contact for families who enroll in the care coordination program. The CHWs empower families around self-management for their child's condition and connect them to resources in the community and the PCMH. More »
Participating families receive comprehensive information on three key messages: knowing your child's condition(s), knowing how to access health care for your child, and keeping your child's condition(s) under control. Families also receive support on self-directed goals around their child's care including but not limited to organization around medications, transitioning from pediatric to adult medicine, organization skills to coordinate care as well as social service referrals that address competing obstacles such as housing, immigration, and employment. The CHWs are based in partner community based organizations, allowing them to remain anchored in the community while also maintaining a strong presence in the PCMHs where they participate in interdisciplinary team meetings and provide linguistically and culturally appropriate tools and education.
We expect that families who complete the CHW care coordination program will be empowered around their child's health care, have addressed social barriers to their child's health, and be better able to manage their child's condition(s).
In January 2012, NewYork Presbyterian Hospital (NYP) and community partners developed the WIN for Diabetes program to address the burden of adult, Type 2 Diabetes in Northern Manhattan. This program serves patients of the Ambulatory Care Network (ACN) Patient Centered Medical Homes (PCMH) 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. More »
Bilingual Community Health Workers (CHWs) serve as the single point of contact for participants who enroll in the year-long care coordination program. CHWs are based in partner community based organizations, allowing them to remain anchored in the community while also maintaining a strong presence in the PCMHs where they conduct sessions and provide culturally appropriate information and support to families who require immediate assistance.
Since January 2012, CHWs have provided information and support to over 4000 patients in the PCMHs and have enrolled over 500 adults with poorly controlled diabetes into the year-long care coordination program. Fifty percent of the participants enrolled for at least 6 months have already demonstrated reduced A1C.
In 2015 NYP and community partners came together to develop a program to support adult patients admitted to NYP hospitals who have two or more chronic illnesses and are at additional risk of readmission within 30 days.
Bilingual CHWs serve as the single point of contact for patients who enroll in the 30 day Transitions of Care program. Participants receive comprehensive information on three key messages: knowing your diagnosis, knowing how to access care and learning how to manage your conditions at home. More »
Participants receive support on setting and meeting goals around their post-discharge care, including, but not limited to: medications, medical equipment, and appointment adherence and accompaniment to medical appointments. They also benefit from social referrals to address barriers such as: housing, immigration, education, and employment, among many others. The CHWs are based in partner CBOs, allowing them to remain anchored in the community while also maintaining a strong presence in the hospital, where they will conduct rounds and provide culturally appropriate education.
CHWs provide diagnosis-specific education in a linguistically and culturally appropriate manner to patients and families. They assess non-medical causes of readmission, such as lack of transportation or financial insecurities. They collaborate with care teams on transition care planning. They coordinate medical and social service needs to overcome barriers to safe transitions. Finally, they strengthen continuity of care between NewYork-Presbyterian Hospital inpatient care and subsequent settings in order to reduce the risk of avoidable readmissions within 30 days.
In 2015, NYP and community partners came together to develop a program to support adults who have at least two comorbid chronic conditions including diabetes, heart failure, chronic respiratory disease and renal failure.
Bilingual CHWs serve as the single point of contact for patients who enroll in the Adults with Complex Care Needs. Participants receive culturally-sensitive, comprehensive information on three key messages: knowing your diagnoses, knowing how to access care and learning how to manage your conditions at home. More »
Participants receive support on setting and meeting goals around their care, including, but not limited to: medications, medical equipment, and appointment adherence. They also benefit from home visits, accompanied provider visits, and social referrals to address barriers such as: housing, immigration, education, and employment, among many others. The CHWs are based in partner CBOs, allowing them to remain anchored in the community while also maintaining a strong presence in the Patient Centered Medical Homes of the Ambulatory Care Network (ACN) where they conduct rounds and provide culturally appropriate education.
As of 2013, over 110,000 New Yorkers were living with HIV. Nationally, it is estimated that 20% of persons are unaware of their status and within New York City, 31.8% of adults report never being tested. On June 29, 2014, Governor Cuomo proposed a major commitment to address HIV within New York State and unveiled the Blueprint to End the Epidemic (EtE) which seeks to dramatically reduce new HIV infections by 2020. This will be accomplished by getting persons tested, linking persons newly diagnosed or out-of-care into medical care, and utilizing biomedical interventions such as Treatment as Prevention and adoption of Pre-Exposure Prophylaxis. More »
In 2015, NewYork-Presbyterian in collaboration with six New York City community based organizations (CBO's) formed REACH (Ready to End AIDS and Cure Hepatitis C). REACH adopts a multi-pronged approach to decrease HIV/Hep C transmission by engaging participants into care, offering treatment for HIV/Hep C and working with those at risk for acquisition within New York City. At the core of this effort are CHWs and Peers from NYP's Center for Community Health and Navigation who are integrated within health care teams across NYP and in local community based organizations to provide peer-level support, education, and to make connections to critical clinical and social services. At NYP Chelsea and Cornell, CHWs and peers are members of the healthcare team where they provide peer-level support, identify social barriers to care and inform care plans. In partnership with several community collaborators, CHWs and Peers are based in multi-service agencies to identify newly diagnosed participants connect them to clinical and social services, including on-site and off-site HIV/Hep C testing.
Growing attention focuses on the connection between physical and mental health, and their link to factors that include socioeconomic and environmental conditions. In Upper Manhattan, residents are less likely to have a regular health care provider than other city residents. One in five adults in this community has no health insurance, and one in six goes without needed medical care, the fourth highest rate in the city. While some of the area's major health problems are related to obesity, diabetes and heart disease, residents experience greater symptoms of psychological distress and mental illness and higher rates of poverty than other city residents. Additionally, it is reported that 41% of New Yorkers do not receive, or delay receiving, mental health services. Many use medical or psychiatric emergency departments as primary sources of care, ultimately leading to poor outcomes. Many lack the support or structure to attend or adhere to long-term psychiatric and medical care. More »
New York-Presbyterian is partnering with community-based organizations to support individuals in addressing the mental health, substance abuse, and social issues that negatively impact their health outcomes. Our Crisis Stabilization project is developing a mental health safety network to keep high utilizers out of the medical and psychiatric emergencies rooms by reaching out in their communities and homes to engage them in their care. Our Behavioral Health-Primary Care Integration project is co-locating primary care and mental health services in our Ambulatory Care Network Clinics and at the Washington Heights Community Service Clinics to improve the health and mental health outcomes of adults and children.
Community Health Workers (CHWs) who are part of the Center for Community Health Navigation are integral members of this multidisciplinary team. They connect patients to medical, mental health, substance abuse, and other services in the community and they work with Health Homes and Health and Recovery Plans (HARP) as part of a long-term care plan. They provide culturally responsive services to educate our patients, identify resources, provide case management and support care coordination activities in ways that support the individual's ownership of his/her recovery and health.
Our complex healthcare system can be challenging to navigate under the best of circumstances and these challenges are compounded for those who are uninsured, undocumented, living in poverty or have limited English proficiency. In 2008, NYP initiated an emergency-department (ED)-based Patient Navigator Program to support, educate and empower patients who are not well connected to a Patient Centered Medical Home and/or insurance to effectively navigate the healthcare system and receive appropriate and continuous care.