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Ambulatory Care Network

collaborator organizations, in addition to focus groups with DSRIP clinical project teams. Trainings covered various topics, including quality improvement and data analytics, cultural competency and health literacy, LGBTQ+ inclusive service delivery, tobacco cessation, collaborative care, health home serving children policy, and motivational interviewing. Over the past year, nearly 200 people have attended webinar trainings and more than 120 people attended in-person trainings.

Division and Community Collaborator Cultural Competency & Health Literacy: The goal of the Division’s Cultural Competency and Health Literacy strategy is to develop a Hospital and community collaborator-focused approach that respects diversity, focuses on clear communication, emphasizes the importance of understanding differences, and engages the individual. The first annual Cultural Competency & Health Literacy in-person training event was held in the fall of 2017. “Instituting Agency Transformation for LGBTQ+ Inclusion” was well attended by Hospital and community agency representatives. There was also a bilingual community health talk for parents of young children. Webinars and tip sheets have been co-developed with collaborators and distributed across the Hospital and community-based organizations with which the Division usually partners.

Tobacco Cessation Services: Ambulatory Care Network’s Tobacco Cessation Services (TCS) facilitates clinician adoption of tobacco cessation. TCS staff members include patient navigators and nurse practitioners who are solely dedicated to TCS or are content experts who integrate TCS into their primary care roles. The TCS program also engaged in provider and community education activities in 2017, including in-person and online learning modules and webinars for NYP employees and NYP PPS members; participation in community health fairs; smoking cessation outreach for adult ACN patients and TCS counseling for providers; and sponsorship of an annual Certified Tobacco Treatment Specialist training for hospitals and community-based organizations. Nearly 3,000 patients have visited with or been engaged by TCS nurse practitioners.

Transitions of Care Program (Lisa McIntyre, Manager: Through DSRIP, the Transitions of Care (ToC) program was implemented to strengthen continuity of care between NewYork-Presbyterian inpatient units and subsequent settings to reduce the risk of avoidable 30-day readmissions to the hospital and/or emergency department. The ToC model is currently operating the NYP Allen Hospital, Milstein Hospital at NYP/Columbia Irving Medical Center, NYP/Weill Cornell, and NYP Lower Manhattan Hospital. The program aims to identify and engage Medicaid patients at increased risk for readmission to provide education on disease and self-management, facilitate timely follow-up with primary care provider(s), and coordinate medical and social service needs to overcome barriers to safe transitions. The ToC program partners with the Center for Community Health Navigation Community Health Worker (CHW) program to reinforce education in a linguistically and culturally appropriate manner, and


3111 Community Health Report 2017  
3111 Community Health Report 2017