For the month of August, the NYP PPS is showcasing the Care Transitions to Reduce 30-Day Readmissions project. With the global DSRIP goal to reduce preventable hospital use by 25%, it is clear why this project is crucial to the success in achieving this goal. The focus of the Transitions of Care (ToC) team is to improve continuity of care and bridge the inpatient setting with any necessary follow-up care for adults who present high risk for readmission for medical or psychosocial reasons. To date, eight Registered Nurse Transitional Care Managers (TCMs) have been onboarded, and the project has developed an evidenced-based protocol to standardize the level of care for over 500 patients.
Working closely with patients, TCMs facilitate delivery of disease and self-management education, create linkages to primary care providers and long-term care management, and create plans of care to ensure safe transitions to appropriate outpatient settings. Additionally, the project seeks to assist in the fulfillment of necessary prescriptions given prior to discharge that can pose challenges for patients. Some sites like NewYork-Presbyterian/Lower Manhattan Hospital have begun delivering medications at bedside prior to discharge.
As of August 2016, the project implemented a Community Health Worker (CHW) model. Through this collaboration, CHWs work closely with TCMs to reinforce disease-focused education, conduct home visits and accompany patients to follow-up appointments. The success of this effort is dependent upon the continued collaboration with a diversified mix of agencies to maximize care transitions resources. These include, but are not limited to, Northern Manhattan Improvement Corporation, Lenox Hill Neighborhood House, Hamilton Madison House, the Center for Community Health Navigation, HIV Center of Excellence, NYP Health Home, NYP Ambulatory Care Network and Metropolitan Jewish Health System Certified Home Health Agency.
In the coming months, the project hopes to continue building out a pharmacy strategy, enhance connections with additional community-based organizations and broaden awareness of project services both internally and externally.
Volunteer Activities: The NYP DSRIP team has been actively engaging the community through participation in volunteer activities at collaborator organizations. On April 13th, the team went to SoHo to work in the God’s Love We Deliver kitchen. The volunteers spent the afternoon helping to prepare the thousands of meals God’s Love We Deliver produces each day. On June 10th, the team went to Thurgood Marshall Academy for Union Settlement’s College Readiness Week, where they spoke to groups of high school students about careers in healthcare, higher education and professional attire. On July 28th, a group volunteered with Union Settlement’s Meals on Wheels program, helping to prepare and deliver meals to senior citizens in East Harlem. To contact the DSRIP team about volunteer opportunities available with your organization, please email us at firstname.lastname@example.org.
The Mexican Coalition, or Coalicion Mexicana, operating since 2013, has achieved a far-reaching and comprehensive impact in their nearly three years of service. Though their physical address is located in the South Bronx, their goal, according to the organization’s President Jairo Guzman, is to go where the need is. Their mission is to “strengthen individual, organizational and community capacities to enable the Mexican and Latin American community to realize their aspirations for full integration – civic, cultural, and political within American Society.” It is this mission that led to their inclusion in the Ambulatory ICU Pediatric project of the NYP PPS – “SKATE – Special Kids Achieving Their Everything” – as it aligned closely with the efforts to improve the lives of children with special needs in the community. The Mexican Coalition is collaborating with the NYP Center for Community Health Navigation and has jointly hired and trained two community health workers on the SKATE project where they are critical to the PPS’s success in helping families overcome all of the various challenges they face in managing their children’s complex medical and social issues.
The Mexican Coalition’s values shape the comprehensive array of services they offer and include empowerment, leadership, education, professionalism, cooperation, support and responsibility. They offer ESL and citizenship courses in the Bronx as well as at other partner sites like churches and schools. Through a partnership with Citizenship Now!, four times per month a lawyer is available for consultations on immigration concerns. Launched in June of this year, their Business Incubator, which walks aspiring female entrepreneurs through the process of launching a business, is geared towards women’s empowerment and is offered completely in Spanish. Additionally, the Mexican Coalition has a 110-hour training program for Community Healthcare Workers (CHWs) which aims to support their preventive health services, wellness program and mobile medical unit. Most services offered by the organization are free or at a minimal fee.
To learn more about the SKATE Project and the CCHN, please click here. (insert link - http://www.nyp.org/clinical-services/ambulatory-care-network-programs/center-for-community-health-navigation/our-work).
For the month of August, we would like to introduce Dr. Margaret R. Nolan DNP, GNP-C, ACHPN, who works as a Nurse Practitioner for NYP and is an integral member of the NYP PPS Palliative Care Project. Dr. Nolan began working on this project in September of 2015 and has served as a passionate and experienced advocate throughout the development process. This project is working to expand access for the Medicaid population to enhanced palliative care and support for patients with advanced illness and their families. Dr. Nolan has contributed to many aspects of this project, including project development and design, direct patient care, networking across the PPS and Ambulatory Care Network, as well as education and advocacy efforts. She is proud to be a driving force in the growth and development of Outpatient Palliative Care Services for the Ambulatory Care Network at NYPH and, most recently, the Ambulatory Opiate Task Force. She states that she celebrates the more subtle accomplishments of the project as well, such as increased communication amongst providers, to whom she has even lent her expertise for consultations.
Dr. Nolan graduated from Stony Brook University School of Nursing with her Doctor of Nursing Practice (DNP). She has also earned her Master of Science in Nursing (MSN) from Hunter-Bellevue School of Nursing, and from Lienhard School of Nursing at Pace University she earned her Bachelor of Science in Nursing (BSN) and her Associate of Science in Nursing (ASN). She is Board-certified in Gerontology and Advance Practice Hospice and Palliative Care along with BLS and ACLS. She has worked in nursing since 1981, with the last 23 years as a Nurse Practitioner. Her career includes a diverse array of settings spanning the Intensive Care Unit, Emergency Department, Mental Health Crisis Team, Geriatric Primary and Urgent Care, Pain and Palliative/Hospice Care, Neurology and academic medicine and research, along with various volunteer service experiences, publications, and committee contributions. Her most recent publications include bimonthly geriatric and nursing articles for Medscape Nurses online and, this year, an article on the impact of education amongst primary care providers in their capacity to lead their patients in advance care planning.
For more information about the NYP PPS Palliative Care Project, please click here. http://www.nyp.org/pps/pps-projects/integration-palliative-care-into-patient-centered-medical-home.
This month we would like to highlight the NYP PPS Behavioral Health (BH) projects, which are focused on providing coordinated, comprehensive services to adults and children with mental health and/or substance use difficulties in order to maximize health outcomes and reduce emergency room and inpatient hospital utilization.
The BH Crisis Stabilization project aims to identify and divert non-emergent psychiatric patients from the medical and psychiatric emergency rooms while linking them rapidly to nearby ambulatory medical, social, psychiatric and substance use providers. The project is staffed by a team of mental health and substance abuse professionals from NYP and three NYP PPS collaborators – Argus Community, ACMH and The Bridge. The project goals will be achieved through two distinct interventions:
The BH Integration project aims to integrate primary and behavioral health care in the two New York State Psychiatric Institute (NYSPI) psychiatric clinics and the NYP Ambulatory Care Network (ACN) medical clinics. At NYSPI, two adult psychiatric nurse practitioners will be embedded in the clinics to provide routine and walk-in primary care to the clinic patients.
The project is in the process of meeting with NYP ACN stakeholders to discuss plans to achieve the Integration Project goals through:
Collaborative relationships with PPS network members providing mental health, substance abuse and social services in Manhattan and the Bronx will be crucial to meeting the BH project goals and anticipated outcomes.
This month, we would like to highlight Marianna da Costa, LMSW, who is a member of the REACH (Ready to End AIDS and Cure Hepatitis-C) Collaborative team at Weill Cornell’s Center for Special Studies (CSS). Marianna was hired in 2015 as part of an initiative to integrate Community Health Workers, Peers and Health Home Care Managers into the HIV Primary Care setting at NYP.
The REACH Collaborative is a partnership between NYP and 6 Community-Based Organizations (ASCNYC, Argus Community, Washington Heights Corner Project, Village Care, Dominican Women’s Development Center and Harlem United). Marianna has developed work flows, referral processes and strengthened relationships with community collaborators to ensure patients have timely access to care and the services they need to remain connected to care. She oversees the Peers and CHW embedded at CSS who are extending the care team into the community by doing home visits, escorting patients to medical and benefits appointments, and increasing access to community-based organizations for wrap-around services.
Marianna graduated from Binghamton University with a BA in Philosophy, Politics and Law. After undergrad, she began working as a Permanency Planner at a large child welfare agency in New York City where she was quickly promoted to a supervisory role. Marianna's interest in HIV began when she was 15 and spent 6 months volunteering in Monrovia, Liberia at an orphanage for children who were HIV+ or whose parents lost their battle with HIV/AIDS. At Columbia School of Social Work, Marianna completed the Advanced Generalist Practice and Programming track focusing on Program Development and Evaluation. At CSS, she combines her clinical and programming skills to develop and implement DSRIP initiatives.
Isabella is a non-profit, non-sectarian organization that has pioneered in the care of the elderly of New York since 1875. Located in the heart of Washington Heights, their mission is to provide quality care through diverse programs designed to promote health and independence within and beyond their walls.
Isabella offers a continuum of care to those in need of support for an aging loved one. Their services include Long Term Care, Sub-Acute Rehabilitation, Ventilator Dependent Care, Respiratory Step Down, Dementia Care, Adult Day Health Care, Independent Senior Living, Home Care, Case Management Program, NORC Programs, Senior Resource Center and additional community-based programs.
Isabella has a deep and long-standing commitment to serving their community – both on and off their campus. As they continue to move forward in the 21st century, they strive to be in the forefront of adopting the latest innovations in good care and continue to work closely with their equally dedicated community partners so that they can deliver the best care possible to those they serve.
Isabella has become a Health Home partner with NewYork-Presbyterian Hospital. The Health Home Program provides Care Management services to make sure everyone involved in an individual’s care is working well together and sharing information that is important in supporting a person’s recovery. Isabella’s Care Managers are caring, professionally trained staff members who have access to a wide array of resources to provide quality care. The purpose of the Health Home Program is to provide the right level of support for the individual so that he or she may be able to live as safely as possible in the community – and avoid unnecessary hospitalizations.
For more information about Isabella, please visit their website at www.isabella.org.
This month we would like to highlight Anny Eusebio, DNP, NP, RN who is a member of the NYP PPS Tobacco Cessation team. Dr. Eusebio joined NewYork-Presbyterian Hospital in April 2016. In her role, Dr. Eusebio helps to bring tobacco treatment services to patients in their medical home by providing services across all sites of the Ambulatory Care Network located on NYP’s West Campus. Her care focuses on providing one-on-one counseling where she works with smoking patients to evaluate their level of smoking, identify their triggers, assess motivating factors, address barriers to quitting and develop a treatment plan. Counseling is tailored to each patient and their unique circumstances. Suggested behavioral modifications are combined with tobacco treatment medication administration and management. The overall approach is intended to be holistic and individualized. Future plans include developing a group counseling program as well as continued efforts to connect with collaborator organizations around how to mutually address the tobacco treatment needs of the PPS population.
Dr. Eusebio graduated from Columbia University with a BA in Psychology, a BS in Nursing and an MSN in Nursing. She obtained her Doctorate in Nursing Practice from Pace University. She has worked in nursing for 16 years, serving for the last 14 years as a Nurse Practitioner. During her career, she has worked in a range of settings including primary care, transitional care nursing, HIV care, diabetes care and more. She has also provided clinical supervision as well as precepted Nurses and Nurse Practitioners. Of note, she previously worked in a tobacco clinic in the Ambulatory Care Network’s Associates in Internal Medical practice providing care to patients who were having difficulty quitting smoking.
The legal services provided at the New York Legal Assistance Group (NYLAG) can play a critical role in DSRIP. Each year, NYLAG attorneys provide free civil legal services to over 76,000 low-income New Yorkers who cannot afford attorneys. NYLAG helps patients find stability in their lives, which in turn facilitates good health and can prevent unnecessary hospital readmission. NYLAG’s comprehensive range of services includes handling public benefits cases (including disability, food stamps, home care and Medicaid/Medicare issues), elder law, housing issues, immigration law, consumer credit law, foreclosure prevention and employment law.
In particular, the LegalHealth division of NYLAG focuses on providing legal assistance to low-income New Yorkers with serious health problems and chronic illness, and handles over 6,000 legal matters annually. LegalHealth currently has on-site clinics located in 24 hospitals and two community-based health organizations throughout the New York City area, including clinics at NewYork-Presbyterian Weill Cornell Medical Center and NewYork-Presbyterian Columbia University Medical Center.
The DSRIP program provides a great opportunity for partners to come together and respond to the complete health care needs of New York City’s communities, including significant social determinants of health. LegalHealth is positioned to assist hospitals achieve many of the measured goals of DSRIP including improved population health and reduction in health disparities. For more information, please see the NYLAG website at www.nylag.org and the LegalHealth website at www.legalhealth.org.
The NYP PPS Adult Ambulatory ICU project is focused on enhancing an integrated continuum of primary care, specialty care and other community and outpatient services for adult patients who have complex medical, behavioral and social co-morbidities. The project targets Adults with Complex Care Needs (ACCM) who are at greater risk for poor outcomes in health-related quality of life and cost of care. The project aims to achieve its goals by:
The current focus of the project is to work with collaborator organizations in aligning them with the Adult Ambulatory ICU practices. One of the initiatives has been to work with the Isabella Geriatric Center, a health home care management agency, to embed their Case Managers within the patient care team at one of the nine PCMH sites. The pilot with Isabella has been a success, as they have been instrumental in providing assistance with high-risk patients who need comprehensive case management. The process has not only created a way to provide warm handoffs, but it has allowed NYP to build a robust relationship with the Isabella team.
The NYP PPS Tobacco Cessation project is focused on integrating evidence-based, sustainable tobacco use treatment into health services across the PPS. The project targets current tobacco users with low socioeconomic status, co-morbidities and poor mental health status. The project aims to achieve its goals by:
The project is currently focused on building clinical services in the Ambulatory Care Network clinics located on the Columbia campus and is pleased to report that Nurse Practitioner, Dr. Anny Eusebio, has joined the team to provide tobacco treatment to patients. The project hosted a Tobacco Treatment Specialist training in April which trained 23 clinicians from across NYP, New York State Psychiatric Institute (NYSPI) and Columbia College of Dental Medicine. The project hopes to repeat this training at the Weill Cornell Campus in early 2017. On April 29, 2016, the project hosted a workshop held exclusively for NYP PPS collaborators on Tobacco Counseling and Pharmacotherapy, which was attended by seven different collaborating organizations. Extra manuals are still available from this workshop for those collaborators who may be interested.
For collaborators who would like to learn more about working on tobacco treatment with the NYP PPS Tobacco Cessation Project, please call Jyoti Parth at (212) 305-2588.
Caption: NYP PPS collaborators attending the Tobacco Counseling and Pharmacotherapy Workshop led by Dr. Tom Payne, Director of the ACT Center Statewide Network for Tobacco Treatment, Education and Research at the University of Mississippi Medical Center
This month we would like to highlight, Matthew Tirelli, PMHNP-C, psychiatric nurse practitioner in our pediatrics department who is a member of the Special Kids Achieving Their Everything (SKATE) Project. Matthew was hired in 2015 as part of an initiative to integrate mental health into the primary care setting. Matthew comes to us from Yale University, with training at the Ackerman Institute for the Family and the Yale Child Study Center. Additionally, he has worked as an in-home crisis therapist and visiting nurse as well as in the foster care system.
In this new role, Matthew works alongside the interdisciplinary team to provide psychiatric training to the pediatric residents, nurses and staff of the Weill Cornell Ambulatory Care Network pediatric site. Part of this role has been to create a much needed resource for the underserved children of NYC who face barriers to accessing high quality mental health care. Being located in a primary care practice has allowed mental health to be integrated into a non-stigmatizing environment, which increases families’ comfort with receiving psychiatric intervention.
Matthew provides short-term stabilization, assessment and psychotherapeutic interventions to the patients who have been identified as needing mental health intervention. He also works in conjunction with the pediatricians, social workers and nurse case managers to create a holistic plan of care and to provide psychological support to the families.
Future plans include further collaboration across the NYP PPS to leverage resources available within the network that will improve coordination of care for families.
This month, we would like to highlight the Riverstone Memory Center, operated by collaborator organization, Riverstone Senior Life Services. Riverstone’s Memory Center may be one of the liveliest spots in the neighborhood. A quick tour of its bright facilities at 99 Fort Washington Avenue in Washington Heights may find clients dancing, singing, drumming, playing piano, cooking, creating handicrafts, celebrating a birthday complete with cake and balloons, cooking a nutritious lunch, preparing for a trip to the Botanical Garden, or even discussing politics. This Social Adult Day program has been operating since 1989 and has been a trusted, engaging and evolving resource for people with memory loss from Alzheimer’s or other dementias – as well as respite and support for their caregivers. In English and Spanish, clients find an alternative to staying at home. At Riverstone, the experienced staff shares smiles and affection to create a safe environment to promote a sense of well-being and independence.
Now operating Monday through Saturday, Riverstone’s Memory Center provides opportunities for mental stimulation, physical activity and social interaction for people in early to middle stages of memory loss. Nutritious, hot lunch and transportation are included in an affordable daily rate that is payable through a managed long term care program or by private pay. Support groups and social services are available at no cost for caregivers, and a newly-awarded grant from the New York State Department of Health will allow Riverstone to begin to greatly expand services for caregivers to include fitness opportunities, stress-relief outlets, legal referrals and more. Riverstone expects to reinstate a successful Memory Café through this funding, which provides a very welcome opportunity for a person with memory loss to spend relaxed time with a caregiver, forming new memories of shared time beyond the bounds of program or home.
The Memory Center is operated by Riverstone Senior Life Services (established in 1985), a bilingual, multi-service senior agency that also provides a neighborhood recreation, education and socialization drop-in center for anyone 60+, social services for benefits assistance, money management and eviction prevention, and a small social adult day program for adults with a developmental disability.
To learn more, schedule a tour or contact a professional, see Riverstone’s website at www.riverstonenyc.org.
The goal of the NYP PPS Pediatric Ambulatory ICU Project, which has been newly renamed to Special Kids Achieving Their Everything (SKATE), is to improve care and health outcomes for high-risk and high-cost pediatric populations with complex care needs. The project targets patients under the age of 21 who meet the definition of a Child with Special Healthcare Needs; patients who either have one or more chronic, complex or unstable medical issues such as cerebral palsy, depression or autism. The SKATE team hopes to achieve their goals by:
Recent activities of SKATE have focused on hiring staff, meeting with collaborator organizations and finalizing the patient registry tool. The group has also engaged a Steering Committee composed of project staff and collaborator organizations which has recently been focused on the development of workflows for the Community Health Worker role.
The Project “Care Transitions to Reduce 30-Day Readmissions” utilizes Transitional Care Managers (TCMs) to coordinate the progression of care from the inpatient hospital into the community, for 30 days post discharge. Prior to discharge, TCMs focus on identifying patients at risk for readmission, and then meeting patients at the bedside to engage into services. Throughout the inpatient course of stay, TCMs collaborate with the interdisciplinary care team and begin to build a Transitional Plan of Care. Once a patient has been discharged, they call patients within 2-3 days and weekly (or more frequently, if needed) thereafter, to help facilitate timely follow-up with primary care providers, link patients to community and long-term care management resources, and provide ongoing education on disease management and medication regimen adherence. The Transitional Care Manager team is comprised of the following staff:
The work of this team is crucial to enhancing care transitions services and collaboration with next-level of care providers in an effort to reduce the risk of avoidable readmissions within 30 days.
Improving the health and quality of life for children and families with special needs is not just the mission of St. Mary’s Healthcare System for Children, it is their driving force. Following hospitalizations in acute care facilities for complications from premature birth, serious illness and catastrophic injury, or when special services for chronic conditions are needed, children and their families come to St. Mary’s to receive care, learn to manage their illness or injury and achieve a better quality of life.
Since their founding as New York City’s first medical facility for children in 1870, St. Mary’s has grown to serve thousands in greater New York City and Long Island through a network of inpatient, community and home care programs. They are one of New York State’s largest providers of long-term pediatric health services. In addition to their flagship inpatient facility, St. Mary’s Hospital for Children, they operate various long- and short-term home and community programs, including St. Mary’s Home Care, a certified home health agency; St. Mary’s Community Care Professionals, a licensed home care services agency; and comprehensive case management programs. Additional centers of excellence include a Pediatric Day Healthcare Program, Center for Pediatric Feeding Disorders, Early Education Center (medical special education preschool) and St. Mary’s Kids at Roslyn, a dynamic therapy center and sensory integration facility.
St. Mary’s is excited to partner with the NYP PPS on several DSRIP initiatives to help improve care for high-risk pediatric populations with special healthcare needs. St. Mary’s expertise in case coordination and management for children with complex and chronic health conditions will provide a post-acute continuum of care for the young patients treated across the network.
For more information about St. Mary’s, please visit: http://stmaryskids.org/.
This month, we would like to highlight the work of the Palliative Care Project. Palliative care aims to improve the quality of life of patients and families facing complications associated with potentially life-limiting or life-threating conditions. The goal is to provide symptom relief and emotional and spiritual support services throughout the course of a patient's illness.
DSRIP funding has made it possible to bring palliative care services to the Ambulatory Care Network on the NYP West Campus and the program went live in February 2016. The interdisciplinary team, which is comprised of a Nurse Care Manager, Social W orker, Nurse Practitioner and Physician, provides assistance to the patient and family with complex decision-making, advises on advance care directives and serves as an extra layer of support during times of crisis and loss. The program also focuses on developing primary care providers' ability to provide generalist-level palliative care to their patients.
Key components of the program include:
For 25 years, ASCNYC has helped tens of thousands of New Yorkers recover from addiction, access medical care, escape homelessness, rejoin the world of work, overcome isolation-and lead healthier, more self-sufficient lives. ASCNYC has earned the trust of New York City's most vulnerable communities, built strong in-roads into the hardest-to-reach areas and pioneered the most effective services to get people living with HIV and other chronic illnesses back on their feet. ASCNYC's individualized, full-service approach gives each person the unique mix of support he or she needs to feel better, live better and do better.
"Positive Change" is the term ASCNYC uses to describe the outcomes it seeks for its clients. For many ASCNYC clients, an additional outcome is the chance to give back to the organization by joining the staff.
To learn more about ASCNYC, please visit www.ascnyc.org . In addition , NBC New York News 4 at 7 recently did a segment on ASCNYC in recognition of its 25 year history of promoting positive change for New Yorkers seeking health, recovery, and a better future as they navigate life with HIV and other chronic health conditions. View the segment here .
ASCNYC's peer education and training program, known as the Peer Training Institute (PTI), is the biggest and one of the best in the nation. PTI's nearly 100 Peer Educators include persons living with or at-risk of HIV/AIDS, those new to or struggling with recovery from substance use as well as those more seasoned in the recovery process. Armed ASCNYC Peer Educators, Staff and Executive Director, Sharen Duke Photo Credit: David Nager/ASCNYC with skills and information, Peer Educators maximize ASCNYC's impact by delivering community education and health coaching to 5,500 New Yorkers every year. In return, Peer Educators are provided with job-readiness skills training to empower them to become community leaders and role models, inspiring others to make healthy choices. The collaboration with the NewYork-Presbyterian Performing Provider System is key to the success of many of ASCNYC's peers finding part-time internships, functioning as job readiness and skills development educators and peer navigators, hopefully leading to full-time employment.
For more information, please visit http://www.ascnyc.org/eng/peer-education-and-outreach/
This month, we would like to highlight the role of our Patient Navigator Program Managers. Patient Navigators are an important element of the NYP PPS DSRIP efforts. Building upon the successful Patient Navigator Program established at NYP's Columbia campus in 2008, Emergency Department-based Patient Navigators offer peer-level support, education and connections to health insurance as well as make follow-up primary and specialty care appointments for patients who are not well established with care. Patient Navigators also provide post- discharge support to help ensure that patients are able to make it to their follow-up appointments. Patient Navigators are members of the Emergency Department and Patient-Centered Medical Home (PCMH) care teams and they, along with the two Patient Navigator Program Managers, are part of the Center of Community Health Navigation which encompasses all Patient Navigator and Community Health Worker efforts across three NYP sites. Following are the names of the two NYP Program Managers and the specific sites with which they are affiliated:
This month we would like to highlight the exciting work of the Emergency Department (ED) Care Triage project. This project features the innovative use of a Patient Navigator model to address the healthcare access, educational and cultural influences of ED utilization for non-acute care. Patient Navigators meet with patients who are identified as high-risk following ED triage. The Navigators initiate a peer-support assessment to both learn the patient's barriers to outpatient care and educate them on how best to navigate the health care system. Working with the ED care team, the Navigators subsequently focus on identifying and scheduling appropriate primary care, specialty care and non-physician services for the patient. The Navigators also address any obstacles the patient may encounter in adherence with their post-ED care, including linking them to financial assistance, social services, and community-based resources such as home care. Post-discharge, the Navigators conduct appointment reminders and post-appointment follow-up calls to optimize patient compliance with the discharge plan and enhance patient education and satisfaction. The primary goal of this project is reduce ED encounters and hospital admissions for non-acute care by establishing continuity of care with longitudinal primary care at medical homes. Current activities of the project have focused on integrating the Navigators early in patients' emergency department visits, launching of the Patient Navigator Program at the Weill Cornell campus (including hiring and training the local team), and recruitment of the Lower Manhattan Hospital campus team members.
We would like to highlight Patricia Hernandez, LCSW who serves as Program Manager for Team-Based Care for the DSRIP projects. Patricia joined NYP in 2012 as the first Behavioral Health Care Manager in the Office of Care Management. In this position, she worked with patients with behavioral health needs by providing them with care management services. In 2014, Patricia became the Manager of the NYP Health Home where she oversaw care coordination activities for NYP's Health Home patients in its internal care management program as well as in the eight community-based organizations that provide care coordination to NYP patients. In December 2015, Patricia joined the DSRIP team as Program Manager for Team-Based Care. In this role, she will aid in the creation of IS-enabled, team-based care workflows involving Allscripts Care Director, Healthix and other information services. She will also be responsible for helping to implement Healthix at collaborator organizations. Given Patricia's clinical background and care management experience, she is able to understand team-based care workflows and how IS tools can assist in communication among the members of the NYP PPS. By having well-defined workflows to support team-based care and IS tools to aid in collaboration, we can provide better, more coordinated care to our most vulnerable patients.
We are pleased to highlight a unique program called "Rango," operated by NYP PPS collaborator organization VillageCare, an organization providing post-acute care, managed long-term care and community health supports. Rango is a web- and app-based program that supports patient activation and treatment adherence through peer support, practical education and helpful tools. It offers a range of features, such as medication and appointment reminders, discussion boards on a variety of healthy living topics, Q&A with Health Coaches and more. Rango is built on expertise in health behavior change and patient feedback has been outstanding. Individuals who are Medicare and/or Medicaid beneficiaries and have been prescribed medications for HIV/AIDS are eligible to participate. Rango can also be adapted to support other patient populations. Organizations interested in the product should contact Allisons@villagecare.org or Jessamineb@villagecare.org for more information.