Our Work

Our Work With Children

Pediatric Community Health Worker Program »

young girl with special needs smiles

The Pediatric 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 Patient Centered Medical Home (PCMH). Read 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.

Since July 2016, 10 CHWs supported 229 children with special health care needs. Eighty-five percent of the caregivers with unmet social needs were successfully connected to social service resources that address needs related to housing, food insecurity, and insurance. Nearly 60% of the 74 participants who completed the program reported decreased levels of distress upon discharge. In addition, to date, CHWs have conducted 481 practice education sessions with caregivers within 5 pediatric clinical sites.

Program Contact

Jaimee Davis, MS

Program Manager: Pediatric CHW Programs
jad9110@nyp.org

Evelyn España, MHA

Program Manager: CHW Programs, Weill Cornell and Lower Manhattan
eve9001@nyp.org

Our Work With Adults

Adult Community Health Worker Program »

In 2017, NewYork-Presbyterian Hospital (NYP) and community partners came together to develop a comprehensive program to support adults with 2 or more chronic conditions and their caregivers. The goals are to improve participants’ health and health care experience by providing culturally sensitive, peer-based community support, enabling them to better access health care, resolve questions and needs in between visits in the medical home, and address social issues that are barriers to achieving health and quality of life. Read More »

Bilingual Community Health Workers (CHWs) deliver education and support around 3 major categories: patient navigation (knowing how to access care), medication management (adherence, knowledge and access), and social determinants (housing, food insecurities, transportation, and immigration). Participants are supported in setting and meeting goals around these specific areas.

Since June 2017, 316 patients were referred to the program. 144 of those referred, enrolled in the program. Of those who have completed the 6-month program (17), 65% have reached their medication adherence goal and 76% have reached their patient navigation goals.

WIN for Diabetes »

woman smiles

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. Read 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 educational 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.

WIN for Diabetes merged with the Adult Ambulatory ICU Program to form the Adult Community Health Worker Program in June of 2017.

Program Contact

Carmen Cruz

Program Manager: Adult CHW Programs
cac9152@nyp.org

Adult Ambulatory ICU »

In 2017, NewYork-Presbyterian Hospital (NYP) and community partners came together to develop a comprehensive program to support adults with 2 or more chronic conditions and their caregivers. The goals are to improve participants’ health and health care experience by providing culturally sensitive, peer-based community support, enabling them to better access health care, resolve questions and needs in between visits in the medical home, and address social issues that are barriers to achieving health and quality of life. Read More »

Bilingual Community Health Workers (CHW), who are based in local Community Based Organizations (CBO), serve as the single point of contact for patients and their caregivers who enroll in the Adult Ambulatory ICU Program. All participants receive comprehensive education associated with three key messages: 1) know your diagnoses, 2) know how to access care and, 3) learn how to manage your condition(s) at home. CHWs apply a peer-based approach to provide culturally sensitive, diagnosis-specific education and all participants receive support to set and meet goals around their self-care, including, but not limited to: medications, medical equipment, and appointment adherence. In addition, participants receive referrals as needed to address challenges associated with housing, immigration, education, and employment, among others.

As of May 2017, 53 patients were referred to the program. Of those referred, CHWs have provided support to 32 patients and 18 of those patients have successfully completed the 3 month program. Of those who have enrolled in the program, 78% received social service referrals to address housing and food insecurities and 94% of those who completed the program have met their medication management goal.

The Ambulatory ICU Program merged with the WIN for Diabetes Program to form the Adult CHW Program in June of 2017.

30-Day Transitions of Care »

elderly man in pajamas

In 2015, NewYork-Presbyterian Hospital (NYP) and community partners came together to develop a program to support vulnerable adult patients recently discharged from NYP hospitals who have two or more chronic conditions, 3 or more admissions in the last 6 months and multiple social determinants of health, putting them at greater risk for readmission.

Bilingual Community Health Workers (CHWs) serve as the single point of contact for patients who enroll in the 30 day Transitions of Care program. CHWs deliver education and support around three key messages: knowing your diagnoses, knowing how to access care, and learning how to manage your conditions at home. Participants are supported to set and meet goals around their post-discharge care, including, but not limited to: medications, medical equipment, and appointment adherence. They also benefit from social referrals to address barriers such as: housing, food insecurity, immigration, education, and employment. Read More »

Since August 2016, 104 patients have successfully completed the program and each were referred to at least 1 community-based social service associated with food, housing, financial and/or transportation insecurities. In addition, 82% of those who completed the 30 day Transitions of Care Program were not readmitted within 30 days of discharge.

Program Contact

Carmen Cruz

Program Manager: NYP/Columbia
cac9152@nyp.org

Evelyn España, MHA

Program Manager: NYP/Weill Cornell and Lower Manhattan
eve9001@nyp.org

Adults With Complex Care Needs »

man smiles

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. Read 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.

Program Contact

Carmen Cruz

Program Manager, Adult CHW Programs
cac9152@nyp.org

HIV – REACH Collaborative »

young woman in profile

As of 2017, over 120,000 New Yorkers were living with HIV.1 Nationally, it is estimated that 13% of persons living with HIV are unaware of their status and within New York City in 2015, 37% of adults report never being tested.2, 3 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. Read More »

In 2015, NewYork-Presbyterian in collaboration with six New York City community based organizations (CBO's) formed the REACH Collaborative (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 infection within New York City. At the core of this effort are Community Health Workers (CHW) and Peers from NewYork-Presbyterian's (NYP) Center for Community Health Navigation (CCHN) who are integrated into health care teams across NYP and in local CBO’s 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 who are based in multi-service agencies work with people at risk for or living with HIV and/or Hepatitis C and connect them to clinical and social services, including on-site and off-site HIV/Hep C testing.

As of December 2017, approximately 650 people have received services from one of the CHWs and Peers working with the REACH collaborative. Amongst a subgroup of these patients, nearly ½ received coordination or referral with primary care (CHP) and 61% of patients received a referral to at least 1 CBO for social support. Additionally, the CHWs and Peers conducted a total of 286 HIV rapid test and 266 HCV rapid tests in the community.

  1. New York City HIV/AIDS Annual Surveillance Statistics. New York: New York City Department of Health and Mental Hygiene, 2017. https://www1.nyc.gov/assets/doh/downloads/pdf/ah/surveillance-trend-tables.pdf. Accessed February 1, 2018.
  2. Centers for Disease Control and Prevention. (August 2016). HIV Testing in the United States [Fact sheet]. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-testing-us-508.pdf. Accessed February 1, 2018.
  3. CUNY Institute for Implementation Science in Population Health. (2015). ETE Dashboard: Ending the AIDS Epidemic- HIV Testing in New York City [Dashboard]. http://etedashboardny.org/data/testing/nyc/. Accessed February 1, 2018.

Program Contact

Whitney Ale

Program Manager, Ready to End AIDS and Cure Hepatitis C (REACH)
wva9001@nyp.org

Behavioral Health – Crisis Stabilization »

woman in office looks pensive

In Northern 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 New York city residents. Additionally, 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. Read More »

NewYork-Presbyterian (NYP) is collaborating with community-based organizations to support individuals in addressing the mental health, substance abuse, and social issues that negatively impact their health outcomes. The Crisis Stabilization project works to develop a mental health safety network for high utilizers of the NYP medical and psychiatric emergency rooms and inpatient units, with mental health diagnoses, by reaching out into communities and homes to engage individuals in their care. A multidisciplinary team bridges patients into outpatient treatment.

The Community Health Worker (CHWs) who is part of the Center for Community Health Navigation is an integral member of this multidisciplinary team. They connect patients to outpatient 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. The Community Health Worker provides 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 their recovery and health.

In 2017, 47 patients received 475 services from the Community Health Worker on the Crisis Stabilization Project. 178 of those services were provided face-to-face. Services include linking patients to outpatient mental health care, connecting them to primary medical care, linking to substance abuse services, connecting people into health homes for long-term support, and helping patients engage with other psychosocial supports.

Program Contact

Whitney Ale

Program Manager, Behavioral Health Crisis Programs
wva9001@nyp.org

Our Work With Children and Adults

Emergency Department Based Patient Navigator Program »

patient and administrator talk in exam room

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, NewYork-Presbyterian Hospital initiated an emergency-department (ED)-based Patient Navigator Program to support, educate and empower patients to effectively navigate the healthcare system and receive appropriate and continuous care. Read More »

Located in 5 emergency departments (ED) of NewYork-Presbyterian Hospital, Patient Navigators offer peer-based, culturally relevant education and support to underserved patients. They link patients to health insurance/financial assistance, and schedule primary care and specialty appointments. In addition, Patient Navigators provide appointment reminders and follow-up calls to ensure that patients receive the care that they need.

From December 2008 to December 2017, Patient Navigators supported 120,728 patients in the five Manhattan ED settings. Seventy-seven percent of the 87,912 patients for whom an appointment was scheduled attended the scheduled appointment and 93% of the nearly 50,761 patients without a primary care provider had an appointment with a new provider upon discharge. These outcomes suggest that an ED-based Patient Navigator Program is an effective approach to connect patients with the clinical and social services they need and, ultimately, to better manage their health.

Starting in 2015, Patient Navigators have also become members of five PCMH health care teams, where they participate in interdisciplinary team meetings, serving as a bridge between the ED and PCMH for patients and their caregivers. Through their culturally sensitive, peer-based approach, Patient Navigators empower patients and their caregivers to better understand and access the health and social resources they need.

Program Contact

Monica Milagros Moreyra

Program Manager: NYP/Columbia, Allen Hospital & Morgan Stanley Children's Hospital
mom9031@nyp.org

Erina Greca

Program Manager: NYP/Weill Cornell, Lower Manhattan Hospital
erg9033@nyp.org