NYP Division of Community and Population Health Report

Division of Community and Population Health Report

Table of Contents

A Thank You to Community-Based Organizations 1

Expanding Our Reach to Help More Neighbors 2

Community and Population Health Leadership 4

About NewYork-Presbyterian ............................................................................................ 5

Division of Community and Population Health: Our Mission 6

Clinical Services: Ambulatory Care Network .................................................................... 8

Transitions of Care 9

Ambulatory Care Network Nursing 10 Telehealth 12

Community Health Needs Assessment & Service Plan 14

Community Health Programs (Domains of Health) ......................................................... 15

Maternal and Child Care 18

• Reach Out & Read 18

• Women, Infants, and Children Program (WIC) 19

• Mother and Child Integrated Mental Health Program (MAC-IMP) 20

Youth Development ......................................................................................................... 22

• The Uptown Hub 22

• Compass Program 24

• Lang Youth Medical Program ........................................................................................ 25

• Summer Youth Program 26

Chronic Disease Prevention and Management 28

• ANCHOR (Addressing the Needs of the Community through Holistic, Organizational Relationships) 28

• Health for Life 29

• Building Bridges, Knowledge and Health Coalition 30

• Center for Community Health Navigation ...................................................................... 32

• Choosing Healthy & Active Lifestyles for Kids (CHALK) 34

• Health Home 36

• Manhattan Cancer Services 37

• Outreach Program 38

• Waiting Room As a Literacy & Learning Environment (WALLE) 40

Behavioral and Mental Health .......................................................................................... 42

• Behavioral Health Clinical Services (Outpatient) 42

• Family PEACE 46

• Substance Use Disorder Program 47

• School-Based Health Center Program 48

• Turn 2 Us ....................................................................................................................... 50

Sexual and Reproductive Health .................................................................................... 52

• Family Planning Program and Young Men’s Clinic 52

• Project STAY 54

Education and Training 56 Health Reform .................................................................................................................. 60

Healthcare Networks 62

64

A Thank You to Community-Based Organizations

NewYork-Presbyterian extends our deepest gratitude to all of our community collaborators throughout New York City and Westchester County.

Without you, none of our work would be possible!

Expanding Our Reach to Help More Neighbors

NewYork-Presbyterian has long been dedicated to understanding social determinants of health and how they affect the communities we serve. We have been committed to meeting our neighbors in their communities by setting up practices closer to their homes and establishing highly successful programs in schools, churches, and other places of gathering. We have assessed the needs of our communities and designed programs and interventions to meet those needs—especially for residents who are most at risk—and have consistently delivered high-quality health care for which we are internationally known.

When COVID-19 hit in spring 2020, we had to change course—quickly. As the city went into “pause,” our teams regrouped to find new ways to reach our community members. Technology facilitated this pivot and enabled us not only to sustain connections with the people we serve, but in some cases, improve them. Now, in addition to meeting the needs of our neighbors in their schools, churches, and communities, we have been able to connect with them in their own homes.

Members of the Division of Community and Population Health collaborated to innovate approaches to reach our communities, relying heavily on technology to make this happen. What we accomplished is phenomenal.

• Telehealth. There was a 1,024% increase in video visits, accounting for a quarter of Ambulatory Care Network volume. NewYork-Presbyterian was able to conduct primary care visits, provide behavioral health services to patients of all ages—at a time when people needed it most, during the stress of the pandemic—support first-time parents and parents-to-be, offer on-demand breastfeeding support, and provide family planning counseling, among other services. Patients needing additional care were seamlessly connected with an in-person visit. Video visits were also combined with at-home testing kits to ensure that patients could continue routine screening for sexually transmitted infections.

• Virtual gatherings. Bilingual educational programs about healthy eating, physical activity, and behavioral health were offered to help our community members live their healthiest lives from the comfort of their homes. Virtual meetings enabled community partners to continue convening and strategizing to meet the changing needs of their constituents during this unpredictable time.

• Youth development and employment efforts. Individuals in our Lang Youth, Uptown Hub, and Summer Youth Experience programs were able to participate in virtual events until it was safe for them to return to these valuable in-person experiences. NewYork-Presbyterian also launched the Summer Youth Experience program for participants of Lang Youth, members of the Uptown Hub, and the children of NewYorkPresbyterian employees to provide meaningful in-person internships to 150 youths.

• Returning to “real life.” As New York City began returning to in-person events, New York-Presbyterian teams were there to help by providing temperature screening tools, hand sanitizer, and face masks and shields. When COVID-19 vaccines became available, our nurses, nurse practitioners, and other providers were on the front lines at our primary care sites to vaccinate New Yorkers.

• Community COVID-19 vaccination. In collaboration with New York State, ColumbiaDoctors, and Weill Cornell Medicine, NewYork-Presbyterian opened a large vaccination center featuring 70 vaccine stations at the Fort Washington Armory in Washington Heights in January 2021. More than 153,000 people have been vaccinated against the infection, raising the vaccination rate in Washington Heights/Inwood to 63%. Contributing to this achievement were 103 partnerships with community and faith-based organizations and elected officials; 43,000 community outreach phone calls; 175 vaccine education talks reaching 14,000 individuals in nine languages; and digital publicity throughout our communities and via social media. We launched a second vaccine hub at the Harlem Children Zone Armory and partnered with the Columbia University College of Dental Medicine to pilot a mobile medical unit to vaccinate children and adults.

Technology is a tool, but what is most important is that it has allowed the Division of Community and Population Health to continue doing our important work. From newborns to older adults of all races and backgrounds, individuals of all gender identities and sexual orientation, and people who come to New York from all over the world, we seek to understand our communities intimately and identify what they need from us to promote their well-being. Whether in person or online, we know that good health does not happen without human connection. We remain committed to sustaining that connection, no matter what it takes.

Sincerely,

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

Community and Population Health Leadership

Nelson Mesa Director Quality Improvment Ambulatory Care Network

Andres Nieto Senior Director Community Health Outreach & Marketing

Jennie Overell Director Ambulatory Care Network NewYork-Presbyterian/Columbia

Mark Krugman, RN Director of Nursing Ambulatory Care Network

Diego Arias Director Ambulatory Care Network NewYork-Presbyterian/Cornell

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

Davina V. Prabhu Vice President Ambulatory Care Network

Elaine Fleck, MD Associate Chief Medical Officer Ambulatory Care Network

NewYork-Presbyterian, one of the nation’s most comprehensive, integrated academic healthcare systems, is committed to providing the highest quality, most compassionate care to New Yorkers and patients from across the country and around the world.

Founded 250 years ago with the fundamental belief that every person deserves access to the very best care, NewYork-Presbyterian now encompasses 10 hospitals across Greater New York, nearly 200 primary and specialty care clinics and medical practices, and an array of telemedicine services.

Ranked #1 in New York and #7 in the nation in U.S. News & World Report’s “Best Hospitals” survey, NewYork-Presbyterian Hospital is the only hospital in the nation affiliated with two world-class medical schools, Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons. Its 48,000 employees and affiliated physicians are dedicated to delivering the most innovative, patientcentered care, advancing medicine through groundbreaking research, educating the next generation of healthcare professionals, and serving the needs of our local, national, and global community.

NewYork-Presbyterian/ Weill Cornell Medical Center 525 East 68th Street New York, NY 10065 212-746-5454

NewYork-Presbyterian Lower Manhattan Hospital 170 William Street New York, NY 10038 212-312-5000

NewYork-Presbyterian Allen Hospital 5141 Broadway New York, NY 10034 212-932-4000

NewYork-Presbyterian Brooklyn Methodist Hospital 506 6th Street Brooklyn, NY 11215 718-780-3000

NewYork-Presbyterian Queens 56-45 Main Street Flushing, NY 11355 718-670-1065

NewYork-Presbyterian/ Columbia University Irving Medical Center 622 West 168th Street New York, NY 10032 212-305-2500

NewYork-Presbyterian Morgan Stanley Children’s Hospital 3959 Broadway New York, NY 10032 800-245-KIDS

NewYork-Presbyterian Westchester Behavioral Health Center 21 Bloomingdale Road White Plains, NY 10605 914-682-9100

NewYork-Presbyterian Lawrence Hospital 55 Palmer Avenue Bronxville, NY 10708 914-787-1000

NewYork-Presbyterian Hudson Valley Hospital 1980 Crompond Road Cortlandt Manor, NY 10567 914-737-9000

FACTS AND FIGURES

For more information, visit www.nyp.org and find us on Facebook, Twitter, Instagram, YouTube and at Healthmatters.nyp.org

Division of Community and Population Health: Our Mission

NewYork-Presbyterian’s Division of Community and Population Health collaborates with physician leaders from Columbia University Irving Medical Center and Weill Cornell Medicine to improve the physical, behavioral, and social health and well-being of the communities we serve, with the goal of achieving equity for all.

To attain this mission, our teams are guided by these principles:

• Building strong community partnerships and enhancing capacity to address shared health priorities

• Providing the highest quality evidence-based population level-based care

• Training the next generation of healthcare professionals

• Advancing best practices through community-engaged research

• Actively contributing to a culture of teamwork, respect, safety, and compassion

A Long-Term Commitment to Our Neighbors

NewYork-Presbyterian has long worked to enhance the health of individuals in our neighboring communities. As one of the largest academic medical centers in the country, we leverage our patient care, research, and educational resources to address local health inequities. In the Washington Heights and Inwood (WHI) communities, we have united with our community collaborators for more than three decades to create the infrastructure needed to bolster and continually support vital population health initiatives. We have applied this experience to expand our offerings in other communities throughout New York City and Westchester County.

Whom We Serve

The WHI communities are highly diverse. More than 70% of residents identify as Hispanic and have contended with cultural, social, and language obstacles to care. WHI also suffers from a disproportionate health burden compared to the rest of New York City. One in three residents lives below the poverty line. Asthma, diabetes, heart failure, depression, and childhood obesity are significant health concerns. WHI is a federally designated “empowerment zone,” indicating that it has one of the highest concentrations of poverty in the United States and making it eligible for special grants, loans, and investments to improve residents’ lives.

Some 524,000 people live in the NewYork-Presbyterian/Weill Cornell Medical Center area, which includes communities of the Upper East Side of Manhattan, East Harlem, and northwest Queens. Twenty-five percent of the NewYorkPresbyterian/Weill Cornell region is of Hispanic descent, with an additional 11% African American and 11% Asian/Pacific Islander. Thirty-one percent of the population in this region was born outside the United States. While English is the most common language, 22% report Spanish as their primary language. There are more than 125,000 people on Medicaid living in the NewYork-Presbyterian/ Weill Cornell area, and 13% of residents do not have health insurance.

Clinical Services: Ambulatory Care Network

Transitions of Care

The Transitions of Care (ToC) program strengthens 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 operates at NewYorkPresbyterian Allen Hospital and NewYork-Presbyterian/Columbia University Irving Medical Center.

The goals of the program are to:

• Identify and engage Medicaid patients at increased risk for readmission and provide education for these patients and their caregivers on disease care and selfmanagement

• Facilitate timely follow-up with primary care provider(s)

• Coordinate medical and social service needs to overcome barriers to safe transitions

In 2021, 801 cases were reviewed using our Daily Huddle, and 50 patients were connected to Health Home services. The team continues to include care coordinators from ACMH, Inc.—an agency focused on patients with behavioral health needs—and has benefited from the addition of a peer specialist from our CBO partner, Services for the Underserved.

Ambulatory Care Network Nursing

Nurses in NewYork-Presbyterian’s Ambulatory Care Network (ACN) are committed to ensuring patients receive the best care possible. Working to the highest level of their licenses, they follow the Professional Practice Model, which is characterized by advocacy, autonomy, collaboration, evidence-based practice, and professional development.

Pandemic-Era Support

During the COVID-19 pandemic, nurses and nurse practitioners have been on the front lines of the vaccination effort, administering vaccines at NewYorkPresbyterian primary care sites. At a time when the number of telehealth visits skyrocketed, nurses have taken on active roles in telemedicine at practices where they triage patients and assist them through the telehealth process and follow-up.

Committee Leadership and Participation

Nurses and advanced practice nurses chair, co-chair, and participate in various committees, such as the monthly Practice Committee, Quality & Patient Safety, Magnet Committee, and the Advanced Practice Nurses Committee. They are involved in decisionmaking, collaborate with various disciplines to enhance care, and contribute their input regarding practice and policy changes, evidenced-based projects, and standardization of care.

Expediting Primary Care

Through the Centralized Clinical Telephone Center, nurses take calls from primary care sites to assist patients with prescription refills, triage care, and speed the ability to meet patient care needs—with the goal of decreasing emergency department and walkin visits. This support enables staff at practice sites to deliver care to patients with fewer interruptions.

Supporting School-Based Health Centers

Self-directed advanced nurse practitioners provide comprehensive care, vaccinations, and other services to nearly 6,000 enrolled children and adolescents at seven school-based health centers in the community. Nurses collaborate with medical directors, nursing and operational management teams, school administrators, and other professionals to provide high-quality care to students each day.

Interdisciplinary Collaboration

Nurses collaborate with other disciplines throughout the network on various initiatives, such as:

• The Baby-Friendly Designation, by interviewing patients to evaluate their baseline knowledge, encouraging mothers to breastfeed and providing education on its importance and health benefits for infants, and providing a baby-friendly environment at practice sites.

• Facilitating support groups for siblings of children with chronic conditions, a joint venture between nurses and child life specialists. These siblings often experience high anxiety and sadness. A six-week curriculum was developed to address family dynamics, worries, coping skills, and self-esteem building.

• Serving as facilitators and educators for the Centering program, which provides new mothers with education and support during pregnancy and the early period after childbirth.

Magnet Designation and Journeys

Three NewYork-Presbyterian hospital campuses achieved the prestigious Magnet® recognition from the American Nurses Credentialing Center over the past two years: NewYork-Presbyterian Lower Manhattan Hospital in 2020, and both NewYork-Presbyterian Allen Hospital/ACN West and NewYork-Presbyterian Morgan Stanley Children’s Hospital in 2021. The work to get to this point began years before, with nurses at each location examining data and methods to improve patient outcomes, enhancing communication, and encouraging nursing engagement through collaborative work, peer review, and having a voice to enhance patient care and safety through committees, policy changes, and onsite activities.

Sharing Research and Expertise

Advanced practice nurses are involved in scholarly activities, presenting and publishing their work regionally and nationally.

• Nurse practitioners were involved in the creation of the first LGBTQ+ health rotation for students in the Weill Cornell Graduate School Master of Science in Health Sciences for Physician Assistants.

• Nurses and nurse practitioners at the ACN Audubon and Broadway Practices implemented initiatives to improve timeout/consents compliance. Both practices demonstrated significant improvement from January 2021 through the present, with scores at 100%.

• ACN nurses began a Family Planning service in the Helmsley Tower Women’s Health practice.

• ACN nurses developed a Breastfeeding Education pregnancy timeline, which is slated to be included in MYCare education and sent to patients throughout the pregnancy and postpartum periods.

• An “ACN Day” was introduced as part of the Nursing Orientation curriculum.

Telehealth

In 2018, the Division began implementing a bold vision: integrating virtual care throughout our practices and leveraging telehealth to offer new, innovative services for patients. In March 2020, everything changed. In response to the COVID-19 pandemic, we rapidly and massively scaled up our nascent telehealth program by training more than 870 adult and pediatric providers and scheduling staff to accommodate a 1,024% increase in the volume of video visits. Telehealth visits quickly came to represent a quarter of all visit volume in the Ambulatory Care Network—volumes that were maintained through 2020 and 2021.

Virtual Clinical Triage Center (VCTC)

• In 2020, the VCTC scaled up to support all Columbia University ACN primary care practices. Sick patients who call into the triage center are now triaged by nurses and fast-tracked to same-day video visits with one of our physicians.

• In addition to managing prescription refills, forms, and other patient needs, the VCTC became a crucial part of care coordination for COVID-19 patients during the first surge. VCTC nursing staff managed follow-up care for patients seen at the NewYorkPresbyterian Allen Hospital COVID testing tent and for emergency department discharges, and also supported the COVID remote care program.

Tele-Lactation “On Demand”

In June 2021, the Division launched Tele-Lactation “On Demand.” New mothers can self-schedule video visits with lactation consultants using the Connect patient portal. The program is currently available to babies born at NewYork-Presbyterian Morgan Stanley Children’s Hospital and NewYork-Presbyterian Allen, as well as ACN Pediatrics and ColumbiaDoctors Pediatrics patients.

Virtual Centering Pregnancy

In 2020, the VCTC scaled up to support all Columbia University ACN primary care practices. Sick patients who call into the triage center are now triaged by nurses and fast-tracked to same-day video visits with one of our physicians.

Patient Education & Outreach

• The Division’s expansion of telehealth has always gone hand-in-hand with establishing services to ensure that patients have support when navigating virtual care. Through a patient ambassador program, patients receive pre-appointment technical support calls; this program has now been established as an enterprise-wide service for all patients.

• Our Community Health Workers and Patient Navigators have provided high-touch support to patients, enrolling over 10,000 patients on the patient portal to date. The CHWs and navigators provide patients with more comprehensive, longitudinal support, including referrals to low-cost mobile phone programs.

At-Home Testing

The Division’s Comprehensive Health Program practice paired video visits with at-home testing kits to ensure that patients could continue routine screening for sexually transmitted infections from home to reduce their risk of COVID exposure. Our model was outlined in an article published in Sexually Transmitted Diseases in January 2021 (2021;48(1):e11-e14).

Community Health Needs Assessment and Service Plan

The Division conducts a comprehensive Community Health Needs Assessment (CHNA) every three years to increase our understanding of the health and social needs of the communities we reach. Based on the results, we create a Community Service Plan (CSP) outlining health priorities we will address and our approach to each one. We leverage NewYork-Presbyterian and community resources to decrease local health disparities through innovative population health initiatives, care provider training, scholarship, and research that are collaboratively developed, executed, assessed, and maintained. 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:

• Empower individuals and families to promote health and wellness

• Better navigate local systems of care and local resources

• Improve school readiness and academic achievement

• Ultimately improve quality of life

In 2019, data collection from the CHNA allowed NewYork-Presbyterian to identify the greatest disparities within the communities of highest need, and to align initiatives and partnerships to focus efforts and maximize their return to the communities we serve. Based on these findings, the top four priorities in the Community Service Plan were:

• Prevention of Communicable Diseases

• Mental Health and Substance Use

• Women, Infants, and Children

• Prevention of Chronic Diseases

High-Disparity Areas

Washington Heights

Mount Vernon

Lower East Side

Crown Heights

Corona

Peekskill

A link to the full Community Health Needs Assessment and Community Service Plan for all NewYork-Presbyterian campuses can be found at https://www.nyp.org/about/ community-affairs/community-service-plans

In 2022, a new Community Health Needs Assessment will be conducted along with a detailed Community Service Plan outlining how we will address health disparities.

Community Health Programs (Domains of Health)

The Community Health Needs Assessment results and Community Service Plan initiatives form the foundation of our community and population health programs, which focus heavily on screening, patient navigation, and connection to care. They are designed to benefit our communities through five Domains of Health: ■■ Maternal and Child Care • Mother and Child Integrated Mental Health Program

Reach Out & Read

WIC Program

Youth Development

Compass Program

Lang Youth Medical Program

Summer Youth Program

The Uptown Hub

Chronic Disease Prevention and Management • ANCHOR (Addressing the Needs of the Community through Holistic, Organizational Relationships) • Building Bridges, Knowledge and Health

Center for Community Health Navigation

CHALK • Health for Life

Health Home

Manhattan Cancer Services

Outreach Program • Waiting Room As a Literacy & Learning Environment (WALLE)

■■ Behavioral and Mental Health

Behavioral Health Crisis Program

Family PEACE

School Based Health Center Program

Substance Use Disorder Program

Turn 2 Us

Sexual and Reproductive Health • Family Planning Program & Young Men’s Health Clinic • Project Stay

This report describes each of these programs and links readers to their websites for more information.

Reach Out and Read Program

The national hospital-based Reach Out and Read (ROR) program trains and supports medical providers who give books to children and advice to parents about the importance of reading aloud. This guidance is provided at each well-child visit until the patient reaches age 6. The ROR program of NewYork-Presbyterian/Columbia University Irving Medical Center is one of the largest in New York State.

Key Accomplishments

• Culturally and developmentally appropriate books are given out at each well-child visit from age 6 months to 5 years.

• Pediatricians underscore the importance of reading aloud to help children build strong literacy skills.

• Foster grandparents read to children in waiting rooms at all sites, and volunteers model reading techniques to children in the waiting room, in the presence of their caregivers. This also makes the waiting room environment more pleasant.

well-child visits for children age 6 months to 5 years at Pediatric Ambulatory Care Network sites

books were disseminated by medical providers to patients during well-child visits Pediatric Ambulatory Care Network sites

Women, Infants, and Children Program (WIC)

The Women, Infants, and Children (WIC) program of the Ambulatory Care Network is a federally and state-funded initiative to provide nutrition education and supplemental foods to eligible women and their children. Clients can receive nutritional counseling, healthy lifestyle education, and breastfeeding support. Individualized food packages are provided to eligible participants.

Pandemic Response

As soon as the pandemic began, the program immediately started issuing WIC benefits. Clients received nutrition and breastfeeding counseling and support remotely via telephone—a practice that continued through 2021, as approved by New York State Department of Health. Virtual meetings were held weekly for supervisory staff and monthly (nine meetings in 2020) for all staff.

Key Accomplishments

Despite the challenges of COVID-19, WIC staff were able to shift the way they do business to serve vulnerable members of the community, including pregnant women, infants, and children who were most at risk of contracting the virus. The WIC program received a favorable evaluation from the New York State Department of Health in 2020, with no deficiencies.

Number of People Reached

Mother and Child Integrated Mental Health Program

(MAC-IMP)

The U.S. has the highest rate of maternal morbidity among developed countries, and this rate is three time higher among Black women compared to their White counterparts. Across New York, infants qualifying for Early Intervention services in communities of color and lowincome neighborhoods face considerable barriers and receive services at a far lower rate than children in White or higher-income neighborhoods.

To improve outcomes, strengthen support, and increase access, NewYork-Presbyterian implemented a twogenerational, integrated approach to maternal-infant care in April 2020. This transformative collaboration aligns target health metrics, care approaches, and dyadic interventions across obstetric, pediatric, and behavioral health services in Northern Manhattan community-based practices. The collaborative works with community-based organizations and local leadership to promote community-wide health initiatives and strengthen support networks for young families. The shared goal is to improve the quality of care throughout the continuum of a mother’s and child’s life.

Each of the five MAC-IMP programs is designed to meet the needs of new caregivers at different stages of the perinatal and early childhood periods.

EMBRACE Uptown (Empowering Mothers Birth Rights through Advocacy, Community, and Education) at NewYork-Presbyterian/Columbia University Irving Medical Center offers medical and psychosocial support to new mothers, especially during the 6-week postpartum period. During their second or third trimesters, patients are identified and referred to EMBRACE by their obstetric providers or other staff. Services are offered through a postpartum doula and/or Community Health Worker (CHW). Assessments and services are delivered through a hybrid model combining virtual and in-person activities. This program is made possible through an ongoing partnership with the Northern Manhattan Perinatal Partnership. EMBRACE expansions are under way at NewYork-Presbyterian’s Weill Cornell and Brooklyn Methodist locations, with future plans to serve 1,000 patients throughout Manhattan, the Bronx, and Queens.

HealthySteps is a national evidence-based prevention model designed to build a foundation of health and strong social-emotional development for kids, beginning in early childhood. NewYork-Presbyterian has expanded this model to begin in the prenatal period, offering behavioral health support in the obstetric and pediatric care environments. HealthySteps interventions provide targeted psychoeducation and skills-based coaching. For high-need families, HealthySteps partners with community-based organizations and pediatric providers to address psychological, developmental, medical, and psychosocial concerns. This program operates alongside the CHW program to target families’ social and community needs.

Northern Manhattan Early Childhood Collaborative (NMECC) is a shared partnership between NewYorkPresbyterian/Columbia and local organizations to create an innovative community-driven early childhood collaborative. The mission is to ensure all families with young children in Northern Manhattan can embark upon lifelong trajectories of physical, social emotional, and educational well-being. The model draws on the expertise, strengths, and mission of each organization to better streamline systems, identify gaps, provide support, and serve young families. NMECC is partnering with the Citizens Committee for Children of New York for population data and research support and is collaborating with Literacy Inc. In 2021, NMECC and the Columbia Student Service Corps founded the Determining Eligibility and Resources (DEAR) pilot program, directly assisting families with screening and application processes for government aid.

Obstetric Centering is an innovative, supportive, community-building model of health care. Expectant parents have the option to participate in group-based healthcare visits. They gain more time with providers, have longer prenatal care visits, and can build relationships with other women in the same stage of pregnancy. Patients also receive educational sessions on issues pertinent to the perinatal period, such as newborn preparedness, mental health, child development, family planning, and contraception. Pediatrics is developing plans to offer a similar model of care.

Pediatric Community Health Worker Program, Early Childhood supports caregivers of children with special healthcare needs to understand and manage their child’s condition and to address their social needs. Bilingual CHWs are anchored in community-based organizations while maintaining a strong presence in the hospital, where they provide education and support to patients. In collaboration with the MAC-IMP collaborative, the Center for Community Health Navigation has built upon the existing model to include maternal and infant support. This obstetric CHW program was made possible through support from the New York State Health Foundation for the partnership between NewYork-Presbyterian and the Northern Manhattan Perinatal Partnership. This effort has a special focus on addressing the digital divide among residents in Northern Manhattan, underscoring the potential of healthcare and community-based partnerships to close the access gap for high-need families.

Number of People Reached

People reached to date through EMBRACE Uptown

Dyads referred to HealthySteps across obstetric and pediatric service lines

Families engaged in dyadic behavioral health interventions through HealthySteps

Uptown Hub

The Uptown Hub, a Youth Opportunity Hub initiative of the Manhattan District Attorney of New York’s Criminal Justice Investment Initiative, has served youth and young adults from the Washington Heights and Inwood community since 2017.

A partnership between NewYork-Presbyterian and several community-based organizations, the Uptown Hub provides a free and safe space for young people to create, connect, and thrive. Access to holistic and culturally affirming services and resources is provided.

The objectives of the Uptown Hub are to:

• Cultivate a community that facilitates the engagement and retention of young people in employment-readiness, educational support, wellness, creative youth development, and recreational activities.

• Reduce idle time, risky behaviors, and justice system involvement through an individualized support system that fosters positive relationships with peers and mentors.

• Improve mental and physical health by supporting psychological development and enhancing resilience and acquisition of coping skills.

• Increase the collective impact of youth-serving agencies and expand community awareness of available services through enhanced collaboration.

Pandemic Response

During the pandemic, several programs continued to be provided virtually. For example, virtual workshops were available on topics such as employment, education, health/wellness, and youth development. Participants were also able to engage in psychotherapy visits through telehealth.

Number of People Reached

Members enrolled since program began 793

Community Collaborators

• NewYork-Presbyterian/Columbia University Irving Medical Center

• Northern Manhattan Improvement Corp

Participants in “Learn, Try, Apply” internship program 303

• People’s Theatre Project

• Police Athletic League

• The YM & YWHA of Washington Heights

Participants in virtual workshops 190

Psychotherapy visits provided via telehealth 957

Compass Program

The Compass Program serves transgender and gender-diverse children and adolescents. Located in the Helmsley Tower on the Weill Cornell Medicine campus, the Compass team—an adolescent medicine physician, pediatric endocrinologist, psychiatric nurse practitioner, adolescent social worker, and program coordinator—provides individualized needs assessments, mental health counseling, family support (including links to community resources), and gender-affirming hormone treatment. Other missions of the program include training pediatric providers and clinic staff to provide genderaffirming care and advocating for transgender and gender-diverse patients in the NewYork-Presbyterian system.

Key Accomplishments

In 2020, Compass received 10 new referrals and continued to see established patients. Most came in person, and some visits were done virtually. The team now meets monthly over Zoom for case conference and program updates. Key accomplishments in 2020 included:

• Medical students, pediatric residents, adolescent medicine fellows, pediatric endocrine fellows, and a psychology intern participated in Compass activities to learn about gender-affirming care.

• The program was presented to the Department of Pediatrics in October 2020 during Professors Rounds.

• A new program coordinator joined the team to assist with tasks such as creating an intake form, developing patient education materials and resources, and formalizing the consent process.

Lang Youth Medical Program

The Lang Youth Medical Program is a sixyear enrichment program designed to inspire and motivate underserved youth from the Washington Heights and Inwood communities who are interested in the health sciences.

From grades 7-12, students receive handson learning and mentorship at a world-class academic medical center as well as college preparation support. Learners meet on Saturdays during the school year and during the month of July in the summers.

Pandemic Impact

The COVID-19 pandemic left an indelible mark on the Lang Youth Medical Program, which went into hiatus in March 2020. During this time, Lang Youth staff worked diligently to create a modified curriculum and schedule. Learning and engagement in a remote setting resumed in summer 2020 and continued through spring 2021, after which time participants could once again attend in person.

Expanding Outreach and Support

Historically, the program has always performed outreach efforts within its community of learners to help identify any specific needs (such as medical/behavioral health issues) within their homes. Since the start of the pandemic, Lang Youth staff members increased their outreach to:

• Connect families with housing assistance

• Procure technology from the New York City Department of Education

Key Accomplishments

• In partnership with Development and Audio/Visual, the program successfully launched the hospital’s first virtual largescale event: the Lang Youth Class of 2020 graduation.

• Lang Youth was the first program in the NewYork-Presbyterian Ambulatory Care Network to achieve a 100% vaccination rate among its participants.

Number of People Reached

Persons served in 2020 88

Virtual meetings, classes, and workshops in 2020 50+

Summer Youth Experience Program

The Summer Youth Experience Program provides youth ages 14-24 with enriching summer employment opportunities throughout the NewYork-Presbyterian enterprise and/or the community. In response to the restrictions imposed by the pandemic in 2020, NewYork-Presbyterian’s Division of Community and Population Health partnered with the Department of Human Resources to develop a threepronged approach to connect youth with summer employment experiences:

• “Lear n-Try-Apply,” a virtual experience led by the Uptown Hub in collaboration with the Lang Youth Medical Program and NYPeers.

• In-per son employment through the NYP Summer Experience for children of NewYork-Presbyterian employees.

• Financial suppor t to enroll youth in community-based organization (CBO) efforts.

Number of People Reached

Youth enrolled in the Learn-Try-Apply Virtual Experience in 2020 301

Children of NewYorkPresbyterian employees placed in in-person jobs 153

Youth enrolled in summer work supported by community-based organizations 345

Key Accomplishments

Learn-Try-Apply. Participants benefited from collaborations with the following CBOs:

• Dominican Women’s Development Center (DWDC)

• Northern Manhattan Improvement Corporation (NMIC)

• People’s Theatre Project (PTP)

• Police Athletic League (PAL)

• The YM&YWHA of Washington Heights & Inwood (The Y)

• Azeotrope (Technology Consultants)

• Building Beats

• Center for Sustainable Development at Columbia University

• NYU Tisch School of the Arts – Film Students

• STEM Kids

• Uptown Stories

• Pathways Mentoring

• Young Life

The program included a weekly Speaker Series featuring talks from NewYork-Presbyterian leaders as well as key sports and entertainment figures, one-onone career coaching and support, anti-racism town halls, and behavioral health services Uptown Hub psychologists.

NYP Summer Experience. In addition to their individual jobs, participants enjoyed presentations, discussions, a closing ceremony, and campus-specific celebrations to recognize their accomplishments. CBO collaborators included:

• Westchester County Youth Bureau

• Community League of the Heights

• Chinese-American Planning Council

• Stanley Isaacs

• Queens Chamber of Commerce

• Prospect Park Alliance

CBO-led Summer Experience. This program served 345 youth who were employed as follows:

• Community League of the Heights: 210 youths

• Westchester Youth Bureau: 35 youths

• Chinese-American Planning Council: 15 youths

• Queens Chamber of Commerce: 15 youths

• Stanley Isaacs: 55 youths

• Prospect Park Alliance: 15 youths

ANCHOR (Addressing the Needs of the Community through Holistic, Organizational Relationships)

The Division of Community and Population Health received the Accountable Health Communities grant from the Center for Medicare & Medicaid Innovation in 2017 to address patients’ health-related social needs through universal screening and referrals to community service providers. The Division expanded its tablet-based screening to seven primary care sites, an ambulatory pediatric psychiatry clinic, inpatient labor & delivery unit, and an adult emergency department. In preparation for the Hospital’s transition to Epic, the program worked with its IT partners to build screening and navigation workflows directly into the new electronic medical record.

By screening for health-related social needs and clinical risk factors, the Hospital can identify the most vulnerable patients and improve their access to preventive services through social and clinical interventions in the community.

Key Accomplishments

In 2021, patients had the option of completing New York State Department of Health (NYSDOH) screenings via MyChart, WELCOME, or telephone, for a total of 41,281 screens across all ANCHOR participating sites.

Patients self-administered 57% of the NYSDOH screens via MyChart or WELCOME, and staff members administered 43% of the screens by telephone or in person.

NYSDOH screening results helped identify 63% of patients as no-risk, 29% as low-risk, and 8% as high-risk among ANCHORparticipating sites.

The most common needs identified among low-risk and high-risk patients were food insecurity (38%) and housing (30%).

Health for Life

Health for Life (H4L) is a weight management program centered on helping 4-to-18-yearolds and their families learn to eat a healthier diet and incorporate physical activity into their lives. Participants have been identified as overweight or obese by their primary care physicians. They and their families can engage in individual visits and group programs providing nutrition education and opportunities for physical activity.

Pandemic Impact

H4L switched to a 100% remote format in March 2020, with all clinic visits, parent education classes, and children’s physical activity groups conducted virtually. H4L collaborated with staff from the NewYork-Presbyterian Morgan Stanley Children’s Hospital pediatric weight management program, meeting as a team weekly early in the pandemic to create standards for virtual weight management programming that offer the most effective care to patients and their families.

Key Accomplishments

Key Accomplishments

• To expand the benefits of the program, H4L services were opened to all pediatric patients in the Ambulatory Care Network.

• The attendance rate at clinic visits increased after switching to a virtual format in March 2020.

• Referrals to the H4L clinical program nearly doubled from 2020 to 2021.

• Virtual exercise classes proved to be very popular, especially with school children staying at home during remote learning.

Number of People Reached (2020/2021)

Attendance rate at clinical visits since switching to virtual appointments in March 2020 75%/74%

Referrals to H4L clinical program 400/755

66/88 3

Virtual exercise classes for ages 8-18

Parents who participated in 10-week education and support groups in 2021, with 89% attendance 30

In-person outdoor family meetups in 2021

“This is a wonderful opportunity for parents and children to not only take a hands-on approach to a healthier way of eating, but their lifestyle. This program provides tools including food vouchers, meetings with a nutritionist, and exercise groups to reach your goals realistically. Everyone was very nice, informative, and helpful. I wish it were longer! Thank you so much.” — Health for Life parent

The Building Bridges, Knowledge and Health Coalition

Through Building Bridges, Knowledge and Health (BBKH), faith- and communitybased organizations collaborate to reduce racial/ethnic health disparities and enhance the well-being of residents in Northern Manhattan, Harlem, and the Bronx. Church members are valuable conduits of good health, responding to community health needs and putting interventions in place to achieve meaningful results.

Pandemic Response

During the height of the pandemic, BBKH members regrouped to chart a new path to continue providing support to the coalition’s members. At the first-ever virtual monthly BBKH meeting in April 2020, core member attendance increased by nearly 150 percent. Each monthly meeting addressed current public health emergency concerns and resources to meet them.

Novel programming efforts included:

• A two-part virtual series in June 2020 featuring a community member discussing “Church Readiness in the Midst of COVID-19,” focusing on the church’s role as a pillar of the community during pandemic recovery and planning. Members created and publicized a virtual directory listing congregations providing virtual services.

• The two-day online Fourth Yearly Clergy Summit, addressing “COVID-19 and Building Resilience in the Community” and attended by more than 100 people.

• A Community Memorial Service in December 2020, in partnership with the hospital’s chaplaincy office, local clergy, community vocalists, and an ACN medical provider—attended by more than 30 people.

• Connections with Ambulatory Care Network (ACN) partners to provide information about maintaining good health during the pandemic, particularly for high-risk groups such as seniors.

Support for homeless individuals

• Financial support to fund dinners at the Bowery Mission Women’s Transitional Center.

• Donations of coats to the Bowery Mission, Help USA women’s shelter in Washington Heights, the Dominican Women’s Development Center, and the Church of the Epiphany.

Assistance with re-opening efforts

• Created re-opening guidelines with member churches.

• Provided re-opening packets—including no-touch thermometers, masks, shields, hand sanitizer, and educational flyers—to BBKH members, including the Church of the Epiphany’s dinner service and the NYC Rescue Alliance mobile bus service for the homeless.

• Personalized onsite walk-through assessments to support member re-opening efforts.

Health education and screenings

• A nutrition series for local churches and the Bowery Mission, in partnership with the ACN Nutrition Department.

• In partnership with NewYork-Presbyterian/Weill Cornell Medical Center labor and delivery nurses, bi-monthly Zoom classes for the Catholic-run Good Council Home for pregnant women and their newborns and a year-end baby shower for all residents.

• Temperature screenings and hand sanitizers for the Church of the Epiphany as they transitioned from their sit-down dinner service to a walk-through bagged dinner.

• A full-scale community initiative launched by NewYork-Presbyterian in 2021 included partnering with community churches to provide access to the COVID-19 vaccine for our most vulnerable community residents.

Center for Community Health Navigation

The Center for Community Health Navigation (CCHN) aims to promote healthcare self-management, connect patients with care, and decrease preventable system utilization. The mission of CCHN is to support the health and wellbeing of patients through the delivery of culturally sensitive, peer-based support in the emergency department, inpatient, outpatient, and community settings. Pandemic Response CCHN has adapted to meet the needs of patients and the community where they are today and support them to overcome obstacles on their paths to addressing their health and social needs. CCHN works closely with longstanding community-based organization partners and clinical partners to quickly and effectively enhance its services and support, building in flexibility to ensure that its models can continue to evolve as needed. Toward those goals, the program has:

• Adapted community health worker (CHW) and patient navigator workflows to incorporate MyChart enrollment and navigation support to help patients access and interact with the healthcare system.

• Developed a Tech Readiness Survey to gauge patients’ access to hardware and internet and assess their readiness to use technology.

• Adapted a model to focus on proactive “wellness checks,” with CHWs reaching out to participants to identify urgent needs.

• Conducted proactive outreach to contact Ambulatory Care Network patients who had not been seen in six months or more to reconnect them with care.

• Implemented proactive outreach to connect eligible and interested patients to vaccine appointments.

• Developed and implemented CHW expert panels, with CHWs specializing in certain areas (housing, food insecurity, etc.) delivering a monthly comprehensive training on each topic.

• Establishing a CCHN leadership huddle three days each week to support a cross-site leadership team.

Number of People Reached

Patients enrolled in patient portal by patient navigators and CHWs 10,000+

Key Accomplishments

Wellness checks performed by CHWs 20,000+

Patients screened by patient navigators across 7 emergency departments and 1 inpatient unit 42,941

• Expanded Patient Navigator and CHW models to NewYork-Presbyterian/Weill Cornell Medical Center, NewYorkPresbyterian Lower Manhattan Hospital, NewYork-Presbyterian Brooklyn Methodist Hospital, and NewYork-Presbyterian Queens.

• Developed an Inpatient Navigator Program to support vulnerable patients in need of follow-up support.

• Expanded CHW programming to support the obstetric population.

87%

Percentage of 7,187 patients without a primary care physician who were connected to one upon hospital discharge

Adults and children enrolled in CHW programs 708

• Initiated enhanced social determinants of health screening in three emergency departments.

• Developed Epic electronic medical record forms and associated processes and implemented Epic across all sites.

One-on-one CHW-patient sessions

People attending three diabetes and two asthma workshops

Choosing Healthy & Active Lifestyles for Kids

The goal of CHALK is to lower the prevalence of obesity among children and teens in Northern Manhattan by creating an environment where all families adopt healthy lifestyles as vital components of their lives. CHALK is a collaboration with NewYork-Presbyterian/Columbia University Irving Medical Center and the Northern Manhattan community.

CHALK partners include community organizations and programs, early childhood centers, public schools, faithbased groups, and Ambulatory Care Network outpatient pediatric practices. Using a non-prescriptive approach, participating organizations work with a full-time CHALK staff member. They can choose from a menu of services— such as grant writing, partnership building, promoting healthy food, and active design—to establish their own goals and create projects that meet their wellness needs.

Pandemic Response

The pandemic increased barriers for people trying to access healthy lifestyles. Leaving home for essential work, grocery shopping, food pantry visits, or exercise placed families at risk of COVID-19 exposure. With schools closed for in-person learning, students were unable to take advantage of school meals and physical activity programming. Grab-and-go meals provided by schools made a difference, but the cold meals, varied quality, and distance to travel meant that not all families benefitted. Many households also lost income as businesses shut down or reduced hours, triggering a rise in food insecurity across New York City. These pandemic impacts deepened pre-existing health disparities. CHALK responded by:

• Increasing virtual opportunities for families to engage in physical activity and nutrition education.

• Supporting community-based organizations as they adapted physical activity and nutrition programming to the virtual environment.

• Spearheading an effort to increase access to healthy groceries for thousands of households experiencing food insecurity.

Key Accomplishments in 2020

• When remote learning began, CHALK schools introduced a bilingual, weekly virtual workshop series for public school students, staff, and families. Sessions featured interactive cooking demos, yoga and dance workshops, and an interactive COVID-19 risk and vaccination information session. When families began to spend more time at home, the CHALK Jr. family engagement project was launched. This paid opportunity invited four early childhood center parents to learn about nutrition and physical activity and then lead virtual workshops on these topics for their peers.

• CHALK’s Capacity Building Initiative and mini-grant programs supported youth and wellness-focused organizations transitioning to remote programming. The team provided one-on-one technical assistance, facilitated crisis coaching and consulting projects with Plan A Advisors, and organized interactive webinars on leadership, virtual fundraising, use of social media to support your mission, and building an effective board.

• Food FARMacia rapidly expanded in Northern Manhattan and the Bronx. Participating families from Ambulatory Care Network outpatient practices, District 6 public schools, early childhood centers, and community-based organizations who were enrolled in Food FARMacia or the Corbin Hill Farm Share received a monthly or biweekly box of healthy groceries along with connection to social services, entitlement enrollment, and essential items such as diapers, hand sanitizer, and masks. A home delivery effort increased access for homebound residents.

• The Fruit and Vegetable Prescription Program launched a digital prescription redeemable at farmers’ markets, so patients supported through telehealth visits could continue to access the program and receive fruits and vegetables. Of the 2,368 prescriptions distributed in June-November 2019, nearly half were redeemed. Distance, time constraints, and forgetting or misplacing the prescription were common barriers to prescription redemption.

• Having increased its reach by 950% in Northern Manhattan and the Bronx (from 190 to 1,997 households), CHALK’s emergency pandemic food response further expanded to highrisk communities in Westchester County, Brooklyn, Queens, and Lower Manhattan. Food FARMacy programs were launched at these sites in partnership with local healthcare teams and community-based organizations. CHALK’s combined emergency food distribution efforts reached 5,604 households and distributed 815,978 pounds of healthy groceries to patients.

Health Home

The NewYork-Presbyterian Health Home is a New York State Medicaid program that reimburses community-based organizations for providing high-quality care management services to Medicaid beneficiaries at risk. A dedicated care manager at the Hospital or at a community-based organization is assigned to Medicaid members with complex medical and behavioral healthcare needs. The goal is to reduce avoidable emergency room visits and inpatient stays and improve health outcomes.

The Health Home network includes these care management agencies:

• Asian Community Care Management (ACCM)

• ACMH

• Alliance for Positive Change

• Argus Community Inc.

• CCN General Medicine

• CREATE Inc.

• Isabella Geriatric Center

• NewYork-Presbyterian Ambulatory Care Management

• Riverstone Senior Life Services

• Upper Manhattan Mental Health Center

Number of People Reached

2,000+

Medicaid beneficiaries reached in 2020

Key Accomplishments

• Engaged 120 care coordination staff in the Annual Health Home Engagement Retreat.

• Implemented the Healthy Planet Care Link electronic health record across the Health Home network.

• Provided community support to patients during the COVID-19 pandemic.

• Generated $18.2 million of revenue for the Health Home network since 2017.

Manhattan Cancer Services

The Manhattan Cancer Services Program (MCSP) links underserved individuals in New York State with cancer care, including uninsured people in difficult-toreach communities and those receiving primary care from the Ambulatory Care Network who are outside of guidance-concordant cancer screening. MCSP provides educational programs, no-cost screening and diagnostic services, referrals to treatment, enrollment in the Medicaid Cancer Treatment Program, case management, and navigation services—all available in English and Spanish.

Key Accomplishments

• Recovery of cancer screening and diagnostic services as New York City re-opened after the pandemic pause.

• Five-year continued award from the New York State Department of Health.

• Expansion of patient navigation services.

• Program documentation and reports developed in the Epic electronic medical record.

Outreach Program

The Outreach Program promotes good health and disease prevention through education and early detection. Staff connect community members with primary medical care, with the ultimate goal of reducing health disparities. Community members have access to free screenings, counseling, health insurance information, and culturally relevant educational presentations.

Pandemic Impact

The Outreach Program’s traditional health screenings abruptly halted in the early days of the pandemic, but team members devised novel ways of supporting partner community and faith-based organizations, including:

• Monetary support of the Bowery Mission Women’s Center’s bimonthly dinners.

• Virtual educational programs via Zoom on topics such as nutrition and COVID-19 for the Bowery Mission, HELP USA women’s shelter, and the Good Counsel Home for Pregnant Women.

• Periodic Zoom calls with partner organizations.

As New York City began to re-open in 2020, Outreach staff collaborated with a NewYorkPresbyterian nurse practitioner to offer virtual guidance to partner organizations and in-person walkthroughs of community facilities.

Do we have NYP outreach photos with masks

Number of People Reached

1,000+

Community members vaccinated against seasonal flu

•

Key Accomplishments

Adults vaccinated against COVID-19 at 6-week Armory pop-up clinic 270 Children received COVID-19 vaccine at Armory and Pediatrics 2000 pop-up clinics 100

• In late 2020, annual flu vaccination events could once again be held in the Bronx, Inwood, Washington Heights, and Westchester.

• A major initiative provided COVID-19 vaccines to the community in 2021, including pop-up clinics at the Washington Heights Armory in partnership with the Harlem Children’s Zone and at Pediatrics 2000 locations.

• A special vaccination clinic opened for undocumented pediatric community members in need of childhood vaccines to attend New York City schools.

Key Accomplishments

• Vaccination services have expanded through via Columbia University’s mobile medical unit.

• Recovery of cancer screening and diagnostic services as New York City re-opened after the pandemic pause.

• Five-year continued award from the New York State Department of Health.

• Expansion of patient navigation services.

• Program documentation and reports developed in the Epic electronic medical record.

Distribution of re-opening packet items, including 20,000 facemasks, face shields, and no-touch thermometers.

Waiting Room As a Literacy & Learning Environment (WALLE)

The Waiting Room As a Literacy & Learning Environment (WALLE), an initiative of the NewYork-Presbyterian Ambulatory Care Network (ACN), aims to address the social determinants of health through a twofold approach: enhancing health literacy by providing targeted health education and empowering patients to seek resource referrals to support their social needs. WALLE helps medically underserved patients who are predominantly from Washington Heights, Inwood, and the Bronx, most of whom are native Spanish speakers. Bilingual volunteers are trained in the tenets of health literacy, motivational interviewing skills, and the Transtheoretical Model. The goals of the program are to:

• Provide approaches to improve quality of care and patient satisfaction

• Support clinical staff by connecting patients to community resources that will help address social determinants of health

WALLE staff members aim to achieve these goals by:

• Linking patients with free or low-cost community resources

• Assisting patients with the completion of medical forms, as needed

• Recruiting interns to serve ACN patients

Key Accomplishments

In 2021, the WALLE Program reached out to 14,814 patients and administered 11,020 New York State Department of Health (NYSDOH) screenings across ACN sites participating in the ANCHOR Initiative.

Among patients screened, 3,802 were connected to resources that help address social health-related factors.

Forty-four active WALLE interns from more than 30 higher learning institutions were recruited and trained to serve patients who self-administered the NYSDOH screens via MyChart.

WALLE interns collectively served over 8,000 hours in 2021 to connect 4,657 patients with free or low-cost community resources. In addition, interns supported screening efforts by reaching out to patients who did not have access to MyChart.

Behavioral Health Clinical Services (Outpatient)

The Division of Community and Population Health at Columbia University Irving Medical Center has developed comprehensive Behavioral Health Outpatient Clinical Services for children, adolescents, and adults to better meet the needs of our community. Many services are provided in partnership with community-based programs and/or within community primary care clinics or schools. Behavioral Health Clinical Services include two comprehensive clinical components: Child/Adolescent and Adult clinical services.

Child/Adolescent Behavioral Health Services

Child/Adolescent Psychiatric Services provides the highest quality community-based mental health care to youth and their families. Components of the program include:

• Community and Acute Child and Adolescent Outpatient Services

• Integrated Child and Adolescent Outpatient Services

• Special Needs Clinic and School-Based Mental Health Program

In response to the COVID-19 pandemic, our services remained continuous. All services pivoted to a telehealth platform to meet the needs of the community, which was disproportionately impacted.

Mental health needs influence medical, social, educational, and occupational outcomes for families in the community; our care promotes health and wellness. Direct clinical care serves over 2,000 families annually, with prevention interventions having a wide-reaching impact. Comprehensive clinical services create a spectrum of mental health care reaching from homes and schools in the community to primary care and hospital-based clinic programs. A tiered approach to care equips our partners, reduces stigma, and provides intensive care for those most in need.

Number of People Reached

Children and adolescents who received mental health care 1,635+

Child and adolescent mental health visits 35,000+

Youth impacted by intensive school-based prevention interventions 2,000+

Key Accomplishments

Responding to the community’s mental health needs and crises was an important priority. Utilizing creativity, innovation, technology, and telehealth, the clinical team created continuous access for mental health services. Additional services—such as teacher and caregiver support online and community educational videos in Spanish—were created to help support children, youth, and families in Northern Manhattan. Child/adolescent behavioral health services are integrated into the community to meet families where they are and provide services across diverse settings.

• The Child and Adolescent Community Clinic at NewYork-Presbyterian Morgan Stanley Children’s Hospital provides premier care for families using innovative, evidence-based treatments for children and adolescents from birth through age 21 in their homes, in schools, and in primary care settings.

• The Home-Based Crisis Intervention Program features a fully bilingual English/Spanish team that uses evidence-based approaches adapted for the community to provide the highest quality of care to those with the most need.

• The School-Based Mental Health Program provides psychological evaluation, treatment, consultation, and workshops to children (ages 4-13, grades pre-K through 8), families, and school staff—coordinating with our Home-Based Crisis Intervention Teams to ensure care is integrated from home to school for children in need.

• The Integrated Mental Health Program (IMP), embedded within four community pediatric primary care ACN clinics, provides psychiatric and psychological services. A new team, PARiTY, was initiated to provide enhanced evidence-based mental health services in the primary pediatric clinic.

• The Adolescent Intensive Outpatient Program was started to provide more intensive mental health services for youth and families at risk for emergency department visits or inpatient psychiatric care. This program provided care virtually and in-person.

Specialty programs meeting specific care needs for youth and families include:

• The Special Needs Clinic for families with children who have a chronic illness and are struggling with mental health and medical needs. Family members can receive care alongside their children to improve outcomes and increase access.

• The Promise Project at Columbia (for Learning Disorders), offering comprehensive neuropsychological evaluations and advocacy for underserved children with learning disorders and serving over 300 youths per year. The team provided continuous onsite care; many youth did not benefit from remote learning and reduced support within schools.

• The NewYork-Presbyterian Youth Anxiety Center, serving emerging adults in need of targeted mental health care. The programs support and empower young adults in collaboration with community-based organizations and aim to reduce disparities in access to care. We also provide training sessions and workshops for community providers, teachers, and parents to equip them to provide the highest quality, community-based mental health care.

Behavioral Health Clinical Services (Outpatient) continued

Adult Outpatient Behavioral Health Services

The Adult Outpatient Psychiatry Clinic provides culturally and linguistically responsive mental health care, ensuring that every patient is treated with the utmost respect and empathy and offering the highest quality training to the next generation of clinicians. Individual and group psychotherapy, family and couples counseling, psychopharmacology, psychological testing, and social work consultations are available. Clinicians also address issues associated with the stigma and discrimination that patients with mental illness and their families may experience. Through a centralized intake system, we process referrals to facilitate admission to our clinic and enhance each patient’s psychiatric treatment experience.

Key Accomplishments

During the COVID-19 pandemic, the Adult Outpatient Psychiatry Clinic responded immediately to the increasing mental health needs of the community. Services were continuous and pivoted to virtual and telehealth for patient safety. New services were developed during the pandemic to meet the increased needs of the community, such as the Rapid Evaluation and Disposition Team and the Geriatric Psychiatry Program. Specialty programming includes:

• The Dialectical Behavior Treatment (DBT) program offers all five modes of DBT in Spanish and English, delivered by psychologists, psychiatrists, social workers, and substance abuse counselors.

• The Rapid Evaluation and Disposition Team Clinic has provided care to patients being discharged from an inpatient psychiatric unit or the emergency department without outpatient care. Patients also at risk for emergency department or psychiatric inpatient admissions receive immediate psychiatric care. Utilizing an evidence-based approach, patients receive comprehensive multidisciplinary care to meet psychiatric, medical, and psychosocial needs. The team also provides real-time linkage to long-term mental health care.

• The Critical Time Intervention Program (CTI) provides intensive psychiatric care for individuals living with severe mental illness who are at risk for poor outcomes. These individuals are often not connected to effective psychiatric and medical care and have repeated emergency department visits or inpatient psychiatric hospitalizations. This program provides treatment to individuals within the community to help stabilize their psychiatric conditions while improving psychosocial challenges such as housing, entitlements, or social support.

• The Geriatric Psychiatry Program is a new program that provides specialized psychiatric care to seniors in the community who are disproportionately impacted by the pandemic. This team provides psychiatric and psychosocial care with evaluation, stabilization, and mental health treatment. Outreach work and community partnership with the Senior Center and community-based organizations has helped to optimize the impact of this program.

• Specialty treatment services are provided to LGBTQ+ individuals, people affected by HIV, individuals with co-existing mental health and substance abuse disorders (MICA services), monolingual Spanish-speaking patients, and pregnant and post-partum women.

• Training has been delivered across disciplines, including clinical psychology interns and externs, medical residents, and medical students. In addition, the Adult Integrated Mental Health-Primary Care Program (IMP) provides integrated mental health services to patients in NewYork-Presbyterian ambulatory primary care practices, including consultations and short-term treatment. The IMP program is committed to universal screening for depression and has incorporated the Collaborative Care model, with psychiatrists supervising behavioral care managers to ensure patients achieve meaningful improvement of their mental health symptoms.

The Family PEACE (Preventing Early Adverse Childhood Experiences) Trauma Treatment Center

Family PEACE helps very young children and their families heal after traumatic experiences such as violence and abuse, with the goal of ending intergenerational cycles of violence. Services are available for children up to age 5, their caregivers, and siblings ages 6-12 who may have also been impacted by family trauma. The program’s vision is to promote the inherent strength and authenticity of individuals and families by creating a safe, empowered community for people to feel seen, heard, and valued through self-awareness, cultural attunement, and spiritual sensitivity.

A Holistic Approach

Using a social justice-oriented, holistic approach grounded in the cultural values and norms of the community, Family PEACE offers:

• Traditional psychotherapy and child-parent psychotherapy

• Individual and group therapy for caregivers and siblings

• Spiritual counseling and spirituality groups

• Creative arts and integrative therapies (music and art therapy, yoga) focused on healing the mindbody connection

• Case management and crime victim compensation assistance

• On-site legal services

• Psychiatry

Pandemic Impact

During the pandemic, Family PEACE provided basic needs such as food, face masks, and cleaning supplies.

• Children and families were able to remain safe and engage in mental health services. Therapy toys and art kits were delivered to facilitate mental health services for young children.

• Traditional in-person mental health interventions were replaced with telehealth video visits or telephone calls with patients.

• Direct contact increased and focused on stress management, psychoeducation, and assistance navigating educational, legal, and medical systems. Families had access to free legal services.

• Group services related to nutrition, parent support, art therapy, yoga, and Mommy and Me increased for children and caregivers.

Maintaining Communication

Creating a sense of community kept families engaged, with a virtual clinic fostering a sense of belonging and connection. Innovative approaches to maintaining regular communication included:

• Daily affirmations sent via text

• Updated information related to COVID-19

• Community resources and events

• Spiritual/faith-based directory of online services

Substance Use Disorder Program

Substance Use Disorder (SUD) Peer Navigators are embedded in NewYorkPresbyterian emergency departments and inpatient units and also work remotely to identify and engage patients who have opioid, alcohol, and other substancerelated conditions and connect them with behavioral health services. These services include detox programs, rehabilitation, residential treatment facilities, outpatient care, and medication-assisted treatment (MAT) programs, among others. The SUD team provides care coordination, including arranging transportation to inpatient treatment facilities and warm hand-offs from NewYork-Presbyterian.

Peer Navigators participate in interdisciplinary morning huddles and patient rounds to discuss referrals with NewYork-Presbyterian clinicians, including care coordination teams; discuss barriers to treatment; and collaborate with Transitions to Care. They engage patients who are ambivalent to treatment by utilizing motivational interviewing skills.

Number of People Reached in 2020

1,232

Patients referred by clinicians to the SUD Program

Key Accomplishments

Patients engaged by SUD Peer Navigators in conversations about treatment options and rehabilitation 556

The program began in 2019 with SUD Peer Navigators at NewYork-Presbyterian/ Columbia University Irving Medical Center, NewYork-Presbyterian Allen Hospital, and NewYork-Presbyterian Lower Manhattan Hospital. It has since expanded to include an additional Peer Navigator and Clinical Supervisor at NewYork-Presbyterian/ Weill Cornell Medical Center’s Emergency Department, as well as Peer Navigation in the Comprehensive Psychiatric Emergency Program at NewYork-Presbyterian/ Columbia. Future plans include Peer Navigators at NewYork-Presbyterian Brooklyn Methodist Hospital and NewYorkPresbyterian Queens.

School-Based Health Center Program

The School-Based Health Center (SBHC) Program provides medical and mental healthcare services to students in 23 public middle schools and high schools in New York City. Health educators provide individual counseling, lead classroom education sessions, and train and lead peer educators. By providing services to students within their schools, the program facilitates access to care and prevents lost academic time.

Pandemic Response

With the onset of the pandemic and New York City schools transitioning to remote learning, most SBHC activities were delivered virtually. However, this new model enabled the program to extend its reach and dramatically expand its virtual capabilities and offerings utilizing:

• Digital communication channels such as Google Classroom, email, and text messaging

• In-person tools adapted for the virtual space

• A new online parental consent portal

• The Sleep Challenge and Gratitude Challenge, and events such as the Senior Resource Fair for 12th graders

Key Accomplishments

• Mental health prevention. A broad range of school-based mental health support services have promoted students’ emotional wellbeing and healthy functioning, with the delivery of workshops and presentations for students, caregivers, and school staff. SBHC provided school-wide “universal” mental health services, “selective” services for students at risk of developing mental health or substance use conditions, and “targeted” services for students with diagnosable mental health conditions.

• Telemedicine enabled SBHC staff to continue providing medical care, mental health care, nutrition counseling, and health education—including mental health counseling, contraceptive counseling, and diagnosis and treatment for some common conditions while students were learning remotely. Students could communicate with their providers directly, complete forms, and receive test results through the Connect patient portal.

• NYPeers peer education and youth development. NYPeers Wellness Educators identified from the school student bodies undertake intensive skills-based training and conduct health promotion activities addressing a wide range of adolescent health topics. They have played a critical role in guiding school-based efforts by identifying key teen health needs, collaborating with staff to develop programming, and serving as ambassadors to care.

• Integrative health. Mindfulness, self-hypnosis, acupuncture, acupressure, aromatherapy, and yoga are integrative health modalities offered at SBHC. NYPeers learn many of these techniques and go on to teach their fellow students and even family members.

Turn 2 Us (T2U) promotes mental health and academic success in at-risk children. The program empowers the elementary school community (students, parents/caregivers, and school staff) to engage in healthy lifestyle practices that encourage wellbeing. Enhancing the mental health literacy of school personnel and parents/caregivers equips them to support the progress of our youth emotionally, socially, and academically. T2U aims to raise awareness of the importance of mental health even in the absence of mental health conditions and decreases mental health-related stigma.

Pandemic Response

During the pandemic, mental health needs and social, emotional, and academic stressors greatly increased. T2U pivoted in multiple ways to provide support beyond its intended reach during this time. Some initiatives that were under way at PS 128M when the pandemic hit in 2020 had to be cut short, and all in-person services—including workshops, professional development, and in-class activities—were delivered virtually. While challenging, virtual programming allowed T2U to reach more school sites and community members and extend its reach beyond Northern Manhattan.

• Mental health first aid. In addition to provide mental health literacy, T2U provided mental health first aid to reduce the fear and hesitation when starting conversations regarding mental health conditions—reducing stigma and raising awareness to support others in need.

• 1:1 consults. T2U provided 1:1 consultation as needed and followed up with mental health resources in the community for school personnel and families.

• Virtual workshops ensured T2U was meeting the needs of students, staff, and caregivers. Bilingual PowerPoint slides helped support students’ self-care and learning at home.

• Handouts for caregivers included strategies on how to recognize and manage stress and support their children.

• Hospital support. T2U helped patients register for telehealth visits and reminded them of upcoming appointments.

Addressing Social Injustice

In addition to the pandemic, T2U has been mindfully aware of racial and cultural injustice and discrimination in the country—acknowledging this during our workshops on trauma and stress and including racial trauma and disparities as discussion points. In addition, the program has ensured its materials are culturally and linguistically appropriate.

Key Accomplishments

In the last five years, Turn 2 Us has grown tremendously.

• The 2019 five-year Healthy Tomorrow’s grant has allowed T2U to provide comprehensive services to more school sites (two)—including a ten-week mental health literacy intervention for staff and caregivers, a series of social-emotional learning workshops for students, and support to the school’s Child Study Team.

• Two sports youth development leagues were created for students with at-risk behaviors.

• T2U has maintained technical support for three school sites, such as access to ad hoc workshops and consultation.

Program impact measures:

• Staff impact. Mental Health Literacy professional development trainings for staff were provided across seven school sites, such as self-care strategies during the pandemic, with 77.8% of staff indicating they expanded their knowledge on useful stress management strategies to prevent burnout. Staff requested more workshops.

• Parent impact. Mental Health Literacy parent workshops were provided across three specific school sites and invitations extended beyond. More than 90% of parents reported learning useful strategies for self-care during the pandemic; 80% reported feeling more confident in their ability to teach their children stress management strategies.

• Student impact. Direct educational services about wellness and a mentorship program supported students’ social-emotional well-being. Thirtynine school personnel and 1,113 students were reached by the Healthy Lifestyles Campaign through assemblies and in-class workshops, with 90% of teachers reporting an expansion of student knowledge. After a 6-week virtual mentorship program for 336 fourth and fifth graders, 81.8% of team coaches involved in the initiative reported that the sessions were beneficial for students during these stressful times.

Family Planning Program and Young Men’s Clinic

The Family Planning Program (FPP) offers comprehensive and confidential medical care, sexual health services, mental health support, and health education to adolescents, women, and men. The FPP and Young Men’s Clinic (YMC) have provided family planning and adolescent pregnancy prevention services to members of the Washington Heights/Inwood community since 1976.

The FPP/YMC provides culturally competent education and links patients to care. Highlights include:

• Participation in Youth Pride, Teens Unite for Health, and many other health fairs and community events

• Multi-session workshop cycles with cohorts of participants in job training and educational programs

• Involvement in the Washington Heights & Inwood Coalition Against Interpersonal and Domestic Violence

• A lead role in the Manhood 2.0 initiative, which seeks to engage adolescent boys and young men to reflect on the impacts of harmful gender norms and support them to build healthier relationships while preventing teen pregnancy, dating violence, sexual assault, and LGBTQ+ bullying

Pandemic Response

The FPP continued to meet the needs of the community members it serves by transitioning services to a virtual platform when appropriate. Telemedicine played a significant role in the provision of contraceptive counseling and initiation as well as pregnancy options counseling and referral. Through telehealth visits, patients have also been able to receive diagnostic services and treatment for common conditions such as vaginal infections and urinary tract infections. Many patients receive the care they need without leaving home, and the Connect patient portal has enabled them to communicate directly with their providers and receive test results and forms.

Key Accomplishments

• Contraceptive best practices. The FPP has pioneered best practices which have significantly enhanced contraceptive initiation and compliance across the country.

• Adolescent services. Health educators and social workers help teens learn how to make good decisions, adopt preventive health practices, become better involved with their families, and prevent sexually transmitted infections (STIs) and unplanned pregnancies.

• Integration of HIV prevention services. FPP provides integrated HIV prevention education and rapid testing services. Patients who are not aware of their HIV status are identified and linked with appropriate care. PrEP and PEP (pre- and postexposure prophylaxis) are available.

• Co-located benefits enrollment and access to supportive services. All uninsured patients in the FPP are referred to OneStop Benefits Assistance Patient Navigators to identify, educate, and enroll those who are eligible for public health insurance and other benefits such as food stamps. OneStop staff also help connect patients with GED, ESL, and job training programs.

• Recipient of funding for services to immigrants. The YMC has received grant funding from the New York City Council for services for immigrants, with the goal of reducing health disparities among foreign-born New Yorkers.

Project STAY

Project STAY (Services to Assist Youth) serves young people ages 14-24 living with or at high risk for HIV; justice-involved youth; lesbian, gay, bisexual, transgender, queer, questioning, or pansexual youth; and men who have sex with men. The program aims to:

• Increase access to and the capacity for prophylaxis (PrEP) services

• Increase testing and screening

• Link and engage patients with care

The Project STAY team includes physicians, outreach specialists, social workers, nurses and nurse practitioners, and others dedicated to making sure the young people of New York have ready access to needed healthcare services. Program members work with community leaders, academic scholars, and public health professionals to serve Harlem and other New York City communities through two major programs:

• The Specialized Care Center, providing care for young people who are HIV-positive or at risk for HIV infection.

• The Youth Access Program, which conducts community outreach, screening, and linkage to care for young people engaging in risk-taking behaviors. A youth-friendly primary care clinic provides medical and mental health services for these young people as well.

Pandemic Response

During the COVID-19 pandemic, the Project STAY team leveraged technology to maintain services to vulnerable populations by offering telemedicine visits, including both video and telephone sessions. Staff proactively reached out to patients to ensure linkage to a care coordinator, who assisted with any social determinants of health needs (such as food insecurity and housing).

Project STAY was one of the few sexual health programs in New York City to remain open. The team applied for and received funding to support services such as transportation to visits to decrease unnecessary exposure on public transportation. Patients were incentivized to enroll in the patient portal through offers of gift cards they could use for food and other supplies, and to facilitate telemedicine services.

Education and Training

NewYork-Presbyterian’s community healthcare practices and programs offer diverse educational opportunities for residents, fellows, and other trainees who share a passion and dedication to improving community health. Specialized residency programs for pediatrics, adult medicine, and family medicine offer instruction, mentorship, and exposure to a wide range of healthcare issues and challenges, providing an unparalleled and rewarding experience for physicians early in their careers.

Pediatric Resident Training at NewYork-Presbyterian/Columbia

Mariellen

Lane, MD Professor of Pediatrics, CUIMC Associate Program Director, Pediatric Residency Program

At NewYork-Presbyterian/Columbia, 76 pediatric residents train in primary care at four practices: Audubon, Broadway, Washington Heights, and Rangel. Each resident maintains an active patient panel and engages in preventative care, from birth through adolescence. An additional area of focus is the care of the medically complex child. Residents participate in interdisciplinary team rounds and help coordinate the complex care of their patients with social workers, a care manager, community health workers, and pediatric psychiatric nurse practitioners. Each pediatric resident also participates in a resident-driven experiential-based quality improvement (QI) curriculum embedded in his or her ambulatory practice. Residents develop and lead projects that impact patient care, emphasize interprofessional collaborative teamwork, and employ formal QI training methodology. Most projects have been sustained and spread throughout the Ambulatory Care Network.

Pediatric and Adolescent Resident Training at NewYork-Presbyterian/Weill Cornell

Theresa

Hetzler, MD Assistant Professor of Clinical Pediatrics, Weill

Cornell Medicine

The Ambulatory Care Network Pediatric and Adolescent Practice at Weill Cornell Medicine is the primary location for pediatric resident and medical student training in primary care. Residents learn preventive care from the newborn period through adolescence as well as care of the medically complex child, with residents participating in a team approach uniting social workers, a care manager, community health workers, and psychiatric practitioners. Trainees also learn to manage other special populations. For example, the TAPP program teaches residents and students to care for adolescent mothers and their children, while Health for Life provides instruction on the care of overweight or obese children and adolescents.

Community Pediatric Residents’ Training Program

Sumeet Banker, MD MPH

Assistant Professor of Pediatrics, CUIMC Associate Director Community Pediatrics

Dodi Meyer, MD I ddm11@columbia.edu Professor of Pediatrics, CUIMC

The Community Pediatrics Residents’ Training Program aims to improve the health of children and adolescents in Northern Manhattan communities. The three-year program uses multiple training methodologies to address early childhood development; legislative advocacy and social determinants of health; and children with special healthcare needs. Interested residents are offered focused faculty and peer mentorship, scholarly project ideas in Community Pediatrics, and opportunities to present their work in different venues. Through collaborations between community and academic organizations, innovative pediatric training experiences, population health initiatives, and enhanced academic leadership, program leaders believe it is possible to significantly and permanently improve how pediatricians relate to, advocate for, and remain committed to their patients and communities.

Quality Improvement Initiatives in the Pediatric Residency Program

Mariellen Lane, MD Professor of Pediatrics, CUIMC Associate Program Director, Pediatric Residency Program

Quality Improvement (QI) is a focus area of the Clinical Learning Environment Review (CLER) program of the ACGME. Through the Pediatric Residency experiential learning QI program at NewYorkPresbyterian Morgan Stanley Children’s Hospital, residents create and execute projects in ambulatory practices which influence patient care, promote inter-professional collaboration, and employ formal QI methodology. Each project is presented annually at the NewYork-Presbyterian Morgan Stanley Children’s Hospital Chief of Service. Most projects have been sustained and expanded, resulting in workflow changes in the ambulatory setting and in support of Hospital QI priorities. QI projects have been presented at national meetings and published as scholarly work.

Adult Medicine Resident Training Programs

Associates in Internal Medicine (AIM)

Maria de Miguel, MD, MS

Assistant Professor of Medicine, CUIMC Director of Ambulatory Education

Jessica Singer, MD, MPH

Assistant Professor of Medicine, CUIMC Medical Director, AIM Practice

Washington Heights Family Health Center

Justine Phifer, MD

Assistant Professor of Medicine, CUIMC

Helen Jan, MD

Assistant Professor of Medicine, CUIMC Medical Director, WHFHC IM

Residents in the Columbia University Internal Medicine Residency Program learn to care for a culturally diverse medically complex adult patient population at the Washington Heights Family Health Center (the training site for 15 residents) and the Associates in Internal Medicine (AIM) Practice at NewYork-Presbyterian/Columbia. At the Washington Heights Family Health Center—a multidisciplinary community health center with mostly internal medicine, pediatrics, and ob/gyn services, as well as social work, psychiatry, podiatry, and gastroenterology—residents learn evidence-based, ambulatory care medicine in a Level 3, patient-centered medical home.

The AIM Clinic—the largest provider of adult primary care in Northern Manhattan, serving more than 15,500 adult patients from the surrounding community and being the primary referral site for those discharged from the hospital and emergency room—is the primary training location for 120 residents who interact closely with faculty in smallgroup didactic sessions and through one-on-one patient care teaching.

Weill Cornell Internal Medicine Associates

Judy Tung, MD

Associate Professor of Clinical Medicine, Weill Cornell Medicine

Section Chief, Adult Internal Medicine Chair, Department of Medicine, NewYork-Presbyterian Lower Manhattan Hospital

Fred Pelzman, MD

Associate Professor of Clinical Medicine, Weill Cornell Medicine Medical Director, Weill Cornell Internal Medicine Associates

At Weill Cornell Medicine, faculty and residents practice side-by-side at fully integrated outpatient practice sites— Helmsley Medical Tower (95 residents) and the Wright Center (16 residents)—providing comprehensive care to a diverse patient population. Residents and faculty see privately insured, Medicare, and Medicaid patients in approximately equal proportions. The patient population is socioeconomically, culturally, and linguistically diverse, hailing from the entire NewYork-Presbyterian catchment area: Queens, Harlem, the Bronx, Brooklyn, and the Upper East Side of Manhattan. Residents serve as primary care physicians and become proficient in the essential components of ambulatory medicine, including chronic care, urgent care, telemedicine, prevention and screening, and patient education.

Family Medicine Residency Program

Heather Paladine, MD

Family Medicine Residency Program Director

Assistant Professor of Medicine, CFCM at CUIMC

The Family Medicine Residency Program recruits and trains the community healthcare leaders of the future who wish to care for patients and their families, particularly those with problems unique to underserved urban communities. Residents learn to develop systems to improve the health of whole communities. Program leaders encourage the education of fellow practitioners regarding the impact and influence of family medicine and aspire to create change. Nearly all graduates go on to practice primary care, with more than half practicing in low-income communities that have a shortage of primary care doctors.

Obstetrics & Gynecology Residency Training Program

Ana Cepin, MD

Assistant Professor of Medicine, CUIMC

Charlene S. Emmanuel, MD

Assistant Professor of Medicine, at CUIMC

Medical Director, Ob/Gyn Ambulatory Care Network

The Ob/Gyn Residency Program at NewYork-Presbyterian/Columbia offers 24 residents excellent clinical training from esteemed generalist and sub-specialty faculty members who are leaders in the fields of obstetrics, gynecology, maternal fetal medicine, gynecologic oncology, reproductive endocrinology, and minimally invasive gynecologic surgery. Residents care for a broad range of public and privately insured patients from around the world as well as those from the surrounding neighborhood of Washington Heights. They also benefit from exposure to the services and resources of the renowned NewYork-Presbyterian Morgan Stanley Children’s Hospital, Center for Prenatal Pediatrics, the Mother’s Center for maternal-fetal medicine care, a Level III Neonatal Intensive Care Unit, and the new Roy and Diana Vagelos Education Center—home to the Mary and Michael Jaharis Simulation Center (SIM Center), a major training resource that integrates a standardized patient program, mannequin-based simulations, and procedural skills training to provide residents with practical, hands-on training. Ob/gyn residents are able to care for a patient population that presents incredibly complex genetic, medical, and surgical challenges on a daily basis.

Health Reform

The United States continues to go through an unprecedented transformation in the way health care is reimbursed and delivered to Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. Since the passage of the 2009 American Recovery and Reinvestment Act (ARRA) and the 2010 Patient Protection and Affordable Care Act (“Obamacare”), government payors have been piloting and rolling out numerous programs to encourage better care for individuals, better health for populations, and lower costs. (Source: Center for Medicare and Medicaid Services Three-Part Aim.) The Division of Community and Population Health has been the primary department responsible for participating in and responding to these policy reforms. The following are examples of delivery and reimbursement system changes in which the Division is engaged.

Medicare Shared Savings Program/Accountable Care Organization (ACO)

As part of the Affordable Care Act, Medicare makes it possible for groups of unrelated providers to form Accountable Care Organizations. An ACO assigns responsibility for improving the quality of care and reducing the total cost of care delivered to a specific population of Medicare beneficiaries. Beneficiaries are assigned to ACOs based on their historic relationships with primary care and other outpatient providers. ACOs that show demonstrable improvements in quality measures are eligible to partake in shared savings achieved through the program.

NewYork Quality Care ACO network includes the Weill Cornell Medicine Physician Organization, ColumbiaDoctors, NewYork-Presbyterian Ambulatory Care Network, and NewYork-Presbyterian Medical Groups in Westchester County, the Hudson Valley, and Queens. It has grown to approximately 38,000 Medicare beneficiaries. The ACO is focused on reducing use of inpatient and emergency department services, improving the quality of care delivered, and enhancing the use of data to drive change. As part of this program, the NewYork-Presbyterian Ambulatory Care Network is actively engaged in improving the outcomes of Medicare beneficiaries.

New York State Delivery System Reform Incentive Payment (DSRIP) Program

New York State is in the process of implementing a five-year, approximately $8 billion initiative to fundamentally restructure the healthcare delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. Through DSRIP, organizations work together to form Performing Provider Systems (PPSs)—either coming together under a single new entity or forming a tighter collaborative—to accept responsibility for the health of a Medicaid population in their service area. These PPSs are then responsible for selecting five to ten projects based on a Community Needs Assessment, which includes feedback from community leaders, collaborators, and beneficiaries.

Through DSRIP, the NewYork-Presbyterian Performing Provider System (PPS) was developed to align the quality improvement efforts of 85 organizations—ranging from independent community physician practices to community health centers and community-based organizations to larger, post-acute providers to improve the health of approximately 80,000 Medicaid beneficiaries across New York City. The PPS has the potential to receive up to $97 million in funding over five years if it successfully meets its pay-for-performance goals. The Division has leveraged these resources to add frontline and community-based staff to reach the most vulnerable patients, as well as additional project management, IT, and analytics staff to build new clinical and community programs. The Division has also leveraged information technology to ensure patients have a seamless care experience across the 85 participating organizations

Healthcare Networks

NewYork-Presbyterian endeavors to provide multidisciplinary, exceptional care to our patients. We are committed to ensuring that patients who need post-acute care and outpatient behavioral health care receive the same high-quality services and experience they have come to know and trust from NewYork-Presbyterian, regardless of whether the care provider is a NewYork-Presbyterian entity. To achieve this goal, we have established a referral network of quality providers as well as seamless access, effective communications, and transitions of care among emergency department, acute, post-acute, specialty, and primary care providers. Referral networks developed by the Division of Community and Population Health include:

Skilled Nursing Facility (SNF) and Home Health Agency (HHA) Referral Network

Collaborating with the NewYork-Presbyterian Department of Care Coordination and care coordination leads at the Regional Hospitals, the Division performed a full assessment of facilities and home health agencies throughout the NewYork-Presbyterian and Regional Hospital Network to identify high-quality collaborators. We reviewed Center for Medicare & Medicaid Services (CMS) Nursing Home and Home Health Agency Compare star ratings, reportable CMS measures, volume and acceptance rate of referrals, specialty services offered, and locations. Through continuous communication with agencies and facilities in the NewYork-Presbyterian Referral Network, we are focusing on new opportunities for joint collaboration of program development, patient flow, and quality improvements.

Behavioral Health and Substance Use Disorder (SUD) Referral Networks

To improve the transition from inpatient to outpatient community providers, NewYork-Presbyterian identified high-quality providers of mental health care, SUD treatment, and care management across the NewYork-Presbyterian and Regional Hospital Network region—with the goal of ensuring that vulnerable patients requiring complex care can transition to high-quality ambulatory behavioral health care. These networks have been active and include representation from community agencies, NewYork-Presbyterian Psychiatry ambulatory care clinics, inpatient care providers, and emergency department leadership. NewYork-Presbyterian has been working with community providers to optimize programming that meets community needs, resulting in tightknit, warm handoff referral processes with local mental health and SUD providers.

The Division of Community and Population Health is working closely with NewYork-Presbyterian Care Coordination to evaluate other post-acute care settings where an enhanced relationship through referral network development may be beneficial for the patients we serve. Plans to expand the Referral Network include Pediatric Post-Acute Care, Home Health, and Hospice. These important sites of post-acute care will help to facilitate high-quality care transitions for the patients we serve every day.

The SUD network group coordinated targeted trainings for NewYork-Presbyterian and community providers, such as Medication-Assisted Treatment, the use of Narcan to treat opioid overdoses, a film series addressing bias and stigma, and collaboration with Unitas/St. Marks Institute to pilot a referral process for the Weill Cornell and Columbia University Emergency Departments to expedite “next-day appointments.” The Division also funded two collaborators to expand access to programming for patients with opioid and serious substance abuse disorders: Services for the Underserved, which serves peers in emergency departments, and Recovery Health Solutions, which offers a telephonic access service for expedited referrals of NewYork-Presbyterian patients in New York City’s five boroughs.

Donor Appreciation

THANK YOU to the generous and visionary donors who support our Community and Population Health programs. In partnership with you, we are increasing access to care and improving the health of adults and children throughout the neighborhoods of New York City and Westchester County.

For more information about the Division of Community and Population Health and community health programs at NewYork-Presbyterian, please visit us online at nyp.org/acn