Division of Community & Population Health

Adaptability, Focus, and Community

As our patients and our communities constantly evolve, our approach to health care must remain adaptable. At NewYork-Presbyterian, our commitment to addressing social determinants of health resides firmly at the heart of our mission. We integrate holistic, community-centered approaches within traditional healthcare settings and beyond.

For more than 20 years, the Division of Community & Population Health has led the way, working closely with our neighbors to develop impactful programs, services, and resources that bridge the healthcare gaps they encounter daily. We stand strong with our communities and physician leaders — listening, learning, and striving together to improve the health and well-being of all.

Today the Division provides services in the community and in our hospitals through our community health programs and our Ambulatory Care Network (ACN). Our care encompasses key focus areas, including Maternal and Child Health, Primary Care, Chronic Disease Prevention and Management, Behavioral Health, Youth Development, Sexual and Reproductive Health, and Specialty Care.

Beyond routine medical care, the ACN outpatient practices strengthen their impact by integrating wraparound services that address social determinants of health. By embedding these resources into the care model, in partnership with community health programs, the medical practices not only improve health outcomes, but advance health equity.  This commitment to community-driven care reflects our ongoing dedication to fostering healthier, more resilient populations. Whether in the community, the ACN, or in our inpatient emergency departments, each team member plays an essential role in delivering high-quality care.

Every three years, we take part in a Community Health Needs Assessment (CHNA) to gather feedback directly from community members about the issues they face. We are excited to embark on another CHNA this year. The findings of this assessment will serve as a blueprint for supporting our communities through the programs and services we provide.

Thank you for another year of remarkable achievements and milestones. Your dedication, compassion, and hard work continue to shape our success and advance our mission. I look forward to continuing this important work together.

Sincerely,

Tiffany Sullivan, MPH
Senior Vice President & Chief Operating Officer
NewYork-Presbyterian Physician Services

Our Mission

The mission of the Division of Community and Population Health at NewYork-Presbyterian Hospital, in collaboration with academic partners from Columbia and Weill Cornell, is to enhance health equity and well-being through advanced, evidence-based clinical practice, health programs, training, and scholarship in the communities we serve.

We connect community members and patients with medical, social, and behavioral health care through a wide range of community health programs and practices for children, adolescents, and adults.

The Division of Community & Population Health Includes: Ambulatory Care Network (ACN), Community Health, Care Coordination, Accountable Care Organization (ACO), Access, and Quality.

Guiding Principles

Community Health Assessment & Service Plan

In partnership with the New York Academy of Medicine, NewYork-Presbyterian conducts a comprehensive Community Health Assessment (CHA) every three years to gain an updated understanding of the health and social needs of the communities we serve. The findings of the CHA help inform the development of the Community Service Plan (CSP) which, in alignment with New York State’s Prevention Agenda, outlines the health priorities NewYork-Presbyterian will address and the approach to each one. In addition, the data are utilized to identify priority communities of high need where the CSP interventions are implemented.

The Division develops and implements the CSP programs across the health system by leveraging resources from both the community and within NewYork-Presbyterian. CSP programs address local health disparities through evidenced-based population health initiatives, care provider training, funding opportunities, and research. These activities are collaboratively developed, executed, and maintained in partnership with community-based organizations and departments within NewYork-Presbyterian. The combination of NewYork-Presbyterian’s skills and resources with the talents, energy, and resources of our community partners enables us to achieve our goals. These efforts also support initiatives that:

In 2022, the hospital selected the following Prevention Agenda priorities for its focus during the 2022-2024 Community Service Plan period.

• Prevention of Communicable Diseases
• Mental Health and Substance Use
• Women, Infants, and Children

Domains of Health

Ambulatory Care Network (ACN)

The Division of Community and Population Health provides compassionate and culturally sensitive clinical services to families and individuals through its Ambulatory Care Network in Manhattan, which includes:

• Primary care sites
• School-based health centers
• School-based mental health programs
• Health and mental health
• Specialty practices

The Ambulatory Care Network makes it easier for patients of all ages to access high-quality, affordable, friendly outpatient care in their neighborhoods. We are committed to improving their physical, behavioral, and social health and well-being.

Reducing Health Inequities

Our ultimate goal is to reduce and ultimately erase health disparities by linking our neighbors with the world's best healthcare services. We work to accomplish this through initiatives that:

• Empower individuals and families to promote health and wellness
• Help people better navigate local systems of care and local resources
• Improve school readiness and academic achievement
• Enhance the quality of life for our community

Ambulatory Care Network Community Practices

Volume	2023	2024
Total ACN (WC + CU)	539,141	557,076

Nursing

Telehealth Breastfeeding Education

The Baby Friendly Committee of the Ambulatory Care Network West Campus improved the delivery of outpatient prenatal breastfeeding education. During prenatal care, mandatory topics required by Baby Friendly USA are introduced, discussed, and reinforced with patients to create and nurture an environment that cultivates sustainable practices that embrace and promote exclusive breastfeeding. EPIC optimization allowed for standardization of prenatal breastfeeding documentation across the organization.  

In 2023, the ACN Baby Friendly Committee partnered with the ACN Newborn Clinic to launch monthly telehealth prenatal breastfeeding classes via MyChart. In 2024, the program expanded to two classes per month — one in English and one in Spanish. This ongoing project supports and reinforces the efforts of ACN West, NewYork-Presbyterian Morgan Stanley Children's Hospital, and NewYork-Presbyterian Allen Hospital in promoting and supporting a breastfeeding environment.  

Improving APRN Orientation

A comprehensive orientation manual is instrumental for talent development, confidence building, ease into practice, and retention of employees. In 2024, we spearheaded the Advanced Practice Registered Nurse (APRN) Orientation Index to meet the needs of NewYork-Presbyterian's APRNs.

Compiled through the collaboration of several key stakeholders, including APRNs, physicians, and Hospital leadership, the orientation index addressea requests for standardization in the communication provided to all onboarding APRNs, with the goal of improving their level of comfort during the transition to independent practice. The index sets a precedent for future endeavors, such as a formal mentorship program for ambulatory APRNs, which will further cement the commitment of leadership to support APRNs.  

Nursing Recognition

NewYork-Presbyterian's nurses regularly receive professional awards in recognition of their commitment to their patients and the community.

• On World AIDS Day in 2024, Caroline Carnevale, FNP, MPH, received an award from the New York City Health Department for her contributions to addressing the HIV epidemic in this city. Ms. Carnevale has been instrumental in grant writing and expert practice at the Comprehensive Health Program clinic and beyond. She helped establish mobile vans for testing, counseling, and treatment of sexually transmitted infections in targeted neighborhoods with high rates of infection and a lack of treatment resources.  
• In May 2024, Lucia Amendano, DNP, was recognized by the Nurse Practitioner Association of New York as the NP of the year. Dr. Amendano has exceptional skills in ambulatory and emergency care, occupational health, and telemedicine and works with the ACN West Clinical Telephone Triage Center. She makes presentations at national conferences, authors publications, volunteers in the community, and mentors APRNs.
• In 2024, NewYork-Presbyterian/Weill Cornell Medical Center received redesignation from the American Nurses Credentialing Center’s Magnet Recognition Program^®, the highest and most prestigious distinction that a healthcare organization can earn for nursing excellence and innovation. The credential is considered the gold standard for nursing.

Telehealth

The Division of Community and Population Health leverages digital solutions to enhance opportunities for our patients to access phenomenal health care. We continue to offer virtual visits, both for acute problems and as a part of chronic care management.

Healthcare Networks

To strengthen care transitions and address gaps in critical services, NewYork-Presbyterian has developed innovative programs that support patients with complex needs, including those requiring housing or substance use disorder care. Through partnerships with organizations like Comunilife and the Alliance for Positive Change, these initiatives provide immediate, low-barrier access to essential resources, ensuring continuity of care during vulnerable transition periods.

The Substance Use Bridge Clinic serves as a vital link between hospital-based care and long-term outpatient treatment for patients with substance use disorders, reducing the risk of relapse and promoting sustained recovery. Similarly, the Comunilife partnership enhances post-acute care through medical respite services. Both programs highlight NewYork-Presbyterian’s commitment to holistic, patient-centered care by addressing medical, behavioral, and social needs through multidisciplinary approaches and collaborative networks.

Social Determinants of Health

Addressing social determinants of health (SDoH) is a primary approach to achieving health equity. SDoH, which includes factors such as food insecurity, inadequate or unstable housing, and lack of transportation, significantly contribute to health disparities within communities. By understanding and addressing these underlying social needs, health care institutions can better support vulnerable populations and enhance overall health outcomes.

The Division of Community & Population Health leads innovative programs designed to tackle these challenges and strengthen our communities.

2024 Health Equity Report

Center for Community Health Navigation

The Center for Community Health Navigation (CCHN) supports the health and well-being of patients by delivering peer-based, culturally sensitive care in the emergency department, inpatient, outpatient, and community settings.

Emergency-Department Patient Navigator Program

Our complex healthcare system can be challenging to navigate, especially for uninsured, undocumented people who are living in poverty and/or have limited English proficiency. NewYork-Presbyterian's emergency-department (ED)-based Patient Navigator Program helps patients effectively navigate the healthcare system. Located in seven EDs, bilingual Patient Navigators offer peer-based culturally sensitive education and support and connect patients to health insurance and financial assistance. They also schedule primary care and specialty appointments and provide appointment reminders and follow-up calls.

Community Health Worker Program

Community Health Workers (CHWs) are based in local community-based organizations and also work as members of healthcare teams in NewYork-Presbyterian primary care settings. There are pediatric and adult CHW programs as well as one for obstetric patients. The CHW Program empowers participants with the education, tools, and resources needed to improve their health and well-being.

Health Promotion Program

The CCHN Health Promotion Program supports equitable access to health-related information, resources, and support for patients. Health Promotion Advocates proactively reach out to patients who have not completed the social determinant of health screening to administer the screening and, if needs are identified, to help connect patients to the right support. The team also helps patients navigate the increasingly digital healthcare system.

Leadership

Meet Our Leadership

Publications

Our team has authored and published groundbreaking work showcasing the impact in our communities.