Clinical & Community Strategy

Developing and expanding several institutional projects designed to identify and address disparities

$5M

commitment

Sickle Cell Disease Investments

Sickle Cell Disease (SCD), which affects roughly 100,000 people in the United States, causes red blood cells to form a sickle shape, leading to painful vasoocclusive crises and complications such as stroke, infection, and organ damage. Despite recent medical advances, the median lifespan for individuals with SCD remains just 54 years — far below that of the general population.

In 2025, the Dalio Center conducted a comprehensive assessment of SCD services across NewYorkPresbyterian, engaging multidisciplinary teams at every campus to understand strengths, needs, and gaps in care. This work informed a fiveyear, $5 million plan to enhance SCD services, with investments in social workers, nurse practitioners, and patient coordinators to improve access and continuity of care. The plan also includes funding for projects exploring integrative therapies to support pain management and overall wellbeing.

Our commitment to patient experience continued in 2025 with the second annual Sickle Cell Patient Experience Event, held at the National Basketball Players Association headquarters. More than 100 patients, families, and providers joined the celebration, featuring special guests, including NBA legend John Starks and Brooklyn native Taj Gibson.

Taj Gibson, NBA player, dribbling with a patient during the Sickle Cell Patient Experience Day at the NBPA

Clinical Health Improvement Projects (CHIPs)

Launched in 2024, the CHIPs program was created to elevate and support the ideas of local clinical and operations teams across NewYork-Presbyterian. Recognizing that staff closest to patients and communities often have the most powerful insights into where inequities arise and how to solve them, the Dalio Center designed CHIPs as a mechanism to support locally-driven health equity solutions. With awards of up to $20,000, the program enables local teams to test innovative approaches and drive measurable improvements in care.

After a successful inaugural year, the Dalio Center launched the second CHIPs cycle in June 2025, awarding eight proposals totaling nearly $140,000. Projects began in late 2025 and span a diverse range of equity priorities:

  • Enhancing Heart Failure Self-Management: The NewYork-Presbyterian Brooklyn Methodist Hospital heart failure team aims to improve outcomes and reduce readmissions by equipping patients with selfmonitoring tools and ensuring timely follow-up.
  • Heart Transplant Patient Education Video: The Transplant Service Line is developing multilingual educational videos to better support patients awaiting heart transplant.
  • Sensory-friendly Emergency Department: The NewYork-Presbyterian Lower Manhattan Hospital team is building a sensory-friendly pediatric emergency department by training staff to assess and support patients with autism and sensory processing differences.
  • Communication Cards: Adapting a successful model from NYP Lower Manhattan, the NewYork-Presbyterian Queens emergency department is introducing illustrated communication cards to strengthen communication with Chinesespeaking patients.
  • Nutritional Health Disparities for Patients with Gastric Cancer: The NYP Queens oncology team is addressing nutritional inequities through community events, support groups, and culturally relevant educational materials.
  • 2026 Maternal Health Equity Symposium: The Women’s Health Service Line will be hosting their 2nd annual Maternal Health Equity Symposium, accessible to all campuses across NYP.
  • Therapy for Patients with Substance Use Disorders: The NYP TRANSiT (Therapeutic Resources and Assistance in Navigation to Services while in Transition) clinical team is establishing a structured group therapy program to address gaps in mental health resources for individuals affected by substance use disorder.
  • Primary Care Training Redesign: Teams at the Farrell Health Center and NewYork-Presbyterian Allen Hospital are launching a longitudinal training program to strengthen primary care providers’ advocacy, community engagement, and leadership skills in service of health justice.

Rebeca Hoey, BSN, RN; Elizabeth Robinson, NP; Bryan Smith, MD; Savannah Pohl, MSW

$140k

grant funding

8

projects

$1.8M

funding

Patient-centered Action Network for Data-driven Advancement (PANDA)

Building on the success of the CHIPs initiative, the Dalio Center developed the PANDA as the next evolution of locally driven, equity-focused innovation. Like CHIPs, PANDA is designed to elevate solutions generated by the teams closest to patient care, but with expanded scope, deeper alignment, and enhanced support.

PANDA brings together diverse project teams from across disciplines and campuses to work toward a single, shared outcome measure. At its core, PANDA is a learning network: teams learn from one another, access guidance from the core PANDA leadership team, and benefit from shared tools, resources, and best practices. The goal is to cultivate a community of likeminded teams across NewYork-Presbyterian collectively advancing health equity through datadriven projects.

In 2025, the Dalio Center launched two networks under this model: the Maternal Health PANDA and the Pediatric PANDA.

Maternal Health PANDA

The Dalio Center, in partnership with the Women’s Health Service Line, the Departments of Obstetrics and Gynecology at Weill Cornell Medicine and Columbia University Vagelos College of Physician and Surgeons, and NewYork-Presbyterian’s Department of Quality and Patient Safety launched the Maternal Health PANDA to bring together interventions to reduce disparities in postpartum hemorrhage (PPH). The program awarded $600k in funding over a one-year funding cycle.

The 11 selected projects for the inaugural Maternal Health PANDA include:

  • AMPLIFY Community Engagement and Provider Education: The NYP/Weill Cornell team is empowering community members and clinicians with education and tools for patientinformed care.
  • CenteringPregnancy Group Prenatal Care: NYP Brooklyn Methodist is implementing group prenatal care and peersupport models to strengthen engagement for birthing patients.
  • Cultural Simulation Series: Through evidencebased simulations, the NYP Brooklyn Methodist team is standardizing PPH response and enhancing cultural responsiveness in clinical care.
  • Electronic Fetal Monitoring (EFM) Observer: NYP/Weill Cornell is piloting a dedicated Electronic Fetal Monitoring (EFM) Observer using PeriGen technology to reduce provider bias and advance proactive maternal safety.
  • Implicit Bias Training: The NYP Lower Manhattan team is embedding equity principles into clinical protocols through a series of Courage to Care workshops.
  • Intrapartum Doulas: NYP Morgan Stanley is expanding access to intrapartum doulas by supporting trainees toward Medicaid certification, with the goal of reducing complications during childbirth.
  • Prenatal Iron Screening: NYP Ambulatory teams are conducting focus groups to better understand patient perceptions of prenatal iron screening and address iron deficiencyrelated contributors to PPH.
  • Rapid Response for PPH: NYP Allen Hospital is standardizing emergency preparedness by deploying fully stocked PPH Rapid Response carts to support timely, coordinated care.
  • TeamSTEPPS for Maternal Safety: At NYP Hudson Valley, staff are receiving evidencebased communication and teamwork training to strengthen maternal safety.
  • Simulation Lab Expansion: NYP Queens is launching a new simulation series with the MamaAnne manikin to enhance clinical education and reduce disparities.
  • Spinning Babies Workshops: Across all NYP campuses, teams are integrating physiologic fetalpositioning techniques to increase vaginal birth rates, improving outcomes and reducing PPH disparities.

Maternal Health PANDA Framework

Pediatric PANDA

The Dalio Center, in partnership with the Children’s Hospital of New York at NewYork-Presbyterian, the Pediatrics Service Line, the Departments of Pediatrics at Weill Cornell Medicine and Columbia University Vagelos College of Physician and Surgeons, and NewYork-Presbyterian’s Department of Quality and Patient Safety launched the Pediatric PANDA to focus on the shared goal of ‘Healthy Kids at Home’. The program awarded over $1.2M in funding over a two-year funding cycle.

The 8 selected projects for the inaugural Pediatric PANDA include:

  • Autism Medical Home: NYP Westchester Behavioral Health and NYP Queens are developing an Autism Medical Home program in the Theresa Lang primary care clinic to improve care for children with autism.
  • BOCA SANA (Bridging Oral health and Community Advocacy to Support Access and Navigation Assistance): The Columbia University College of Dental Medicine will expand support services at the pediatric community dental clinic to address the inequitable burden of untreated dental disease among low-income children in Northern Manhattan.
  • Care Pathways for Children at Risk of Agitation: NYP Morgan Stanley is developing and implementing a standardized inpatient agitation pathway to reduce agitation-related adverse events.
  • Home Ventilation Program for Continued Caregiver Education and Support: NYP Morgan Stanley is creating a program to educate and support caregivers of children with tracheostomy throughout the procedure and during the follow-up period.
  • Pediatric Asthma Linkage to Care Program: NYP Morgan Stanley is implementing universal screening for all pediatric patients in the ED to connect high-utilizing patients with severe asthma to pediatric specialists and community-based organizations.
  • PICU Telehealth Follow-Up Clinics: NYP Komansky will expand access to the PICU Follow-Up Clinic by integrating a child life specialist who will identify eligible patients during rounds, educate families, and schedule appointments. Additionally, NYP Morgan Stanley will expand services for post-PICU patients, addressing the complex medical, psychological, and social needs of children after receiving critical care treatment.
  • Transforming Outcomes Through Social Drivers of Health-Responsive Care: NYP Komansky will implement a food insecurity intervention, including home food delivery, for recently hospitalized children who receive followup care in the pediatric clinic.
  • Vaccine Education: Clinical leads at NYP/Columbia and NYP/Weill Cornell are developing an enterprise-wide initiative to address vaccine hesitancy, including the development of patient-centered educational materials designed to support families in making fully informed decisions.

Kidney Disease Education and Engagement

To address disparities in kidney disease, the Dalio Center partnered with the Rogosin Institute in 2022 to launch an education program at NYP/Columbia University Irving Medical Center and NYP Allen Hospital. With support from the Dalio Center, Columbia University continued the program in 2025, engaging family and caregivers, expanding preemptive transplant counseling, and supporting patients pursuing home dialysis.

The program continues to achieve remarkable success, exceeding national and local averages in pre-emptive transplant rates, home dialysis rates, peripheral vascular access placement, and initiation of dialysis without inpatient admission.

Key Accomplishments in 2025

360

patients enrolled in 2025

Cardiovascular Health

Cardiovascular health is a key focus for the Dalio Center, with 2025 efforts centered on cardiac sarcoidosis, heart failure, and hypertension. These efforts complement cardiovascular projects described elsewhere in the report, such as the CHIPsfunded heart failure selfmanagement and heart transplant education initiatives, as well as cardiac amyloidosis research supported through the Health Justice Research grants.

Cardiac Sarcoidosis

Cardiac sarcoidosis is an inflammatory disease in which granulomas form in the heart, disrupting electrical and mechanical function and increasing the risk of arrhythmia and heart failure. Black and African American patients are 2.5 times more likely to develop sarcoidosis and often experience more severe disease and poorer outcomes.

In 2025, an enterprise-wide workgroup of cardiologists and Dalio Center data analysts created a cardiac sarcoidosis registry within our Epic EMR, a standardized outpatient order set, and new patient education materials. Next steps include operationalizing the registry, building a performance dashboard, and advancing patient‑facing educational content.

Heart Failure

The Dalio Center is supporting the rollout of a new EMR‑generated heart failure report that identifies patients across eight acute care hospitals who may benefit from a heart failure consultation. The initial phase focuses on using the report to establish baseline data and highlight priority areas for improvement, with the goal of ensuring that all eligible patients receive timely, appropriate care.

Hypertension

Work on hypertension began in 2025 through a partnership with the Ambulatory Quality team. Together, we have been reviewing hypertension control quality measures across primary care sites and have identified several opportunities for improvement. In 2026, the teams will build on this foundation by focusing on improving hypertension management and control across our ambulatory practices, working to close identified equity gaps and strengthen long‑term cardiovascular outcomes.

Empower: Postpartum Hypertension Monitoring

In May 2024, the Dalio Center funded the launch of the NewYork-Presbyterian Empower program to improve postpartum health outcomes for at-risk individuals, led by Dr. Heather Lipkind, the director of Maternal-Fetal Medicine at Weill Cornell Medicine and a gynecologist-obstetrician at NewYork-Presbyterian/Weill Cornell. In collaboration with the Department of Obstetrics and Gynecology at Weill Cornell, the NewYork-Presbyterian inpatient obstetrics team and the NewYork-Presbyterian Ambulatory Care Network pharmacy team, this initiative provides high risk patients with blood pressure cuffs and education after delivery and clinical pharmacists follow-up remotely with patients to titrate medications.

Preliminary data demonstrate a decrease in emergency department presentations for hypertensive disorders and reduced hypertension-related readmissions among program participants.

Key Accomplishments in 2025

  • 237 patients enrolled in 2025 YTD
  • 195 patients graduated (246 since program start)
  • Connected 45 patients to a primary care provider

Hanlin Li, PharmD, Amber Bradley, PharmD, Jim Thurston, PharmD

81%

of participants engaged in care as of October 2025

The Weill Cornell team has been excellent before and after my pregnancy. I appreciate the team's genuine care for me and my health during our regular check-ins.

My care at Weill Cornell was excellent, and the frequent communication and touchpoints motivated me to keep on top of my health. I felt like everyone I worked with within Weill Cornell really listened to me, cared about my health, and prioritized my wellbeing, which empowered me to manage my own health.

Great team. I love the care and the conversation I was having with the team.

162

unique clients served (as of November 2025)

The Center for Hope & Resiliency (TCHR)

To improve health outcomes in individuals released from incarceration, TCHR provides comprehensive health services, including primary care, mental health, social work, and obstetrics & gynecology care, along with coordinated referrals to subspecialty services such as dental, orthopedics, cardiology, urology, and rehabilitation medicine. The team also connects patients with community partners for employment, education, legal, and housing assistance.

TCHR employs community health workers with lived experience in the carceral-legal system to support outreach and patient navigation; two returning citizens have been hired into these roles. Since launching in January 2024, TCHR has served 162 unique clients across 452 visits and made 179 subspecialty referrals.

In addition to direct clinical care, TCHR is committed to training the next generation of clinical providers. This includes workshops led by Dr. Alwyn Cohall, professor of public health and pediatrics at Columbia University Vagelos College of Physicians and Surgeons and the Mailman School of Public Health, along with formerly incarcerated clients, to enhance medical students' understanding of mass incarceration, social determinants of health, and their impact on health outcomes in vulnerable communities.

Dr. Alwyn Cohall speaking at the Dalio Center’s Five Year Anniversary Celebration