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Chronic Disease Prevention and Management
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 AccomplishmentsKey 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 75%/74% March 2020
400/755
Referrals to H4L clinical program
66/88
30
Virtual exercise classes for ages 8-18
In-person outdoor family meetups in 2021
Parents who participated in 10-week education and support groups in 2021, with 89% attendance
3
“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
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.
Number of People Reached (2020)
25,000+
Community members
12
Online meetings & workshops
580
People attending online events
200
Items of warm weather gear distributed to homeless shelters
1,200
Masks and hand sanitizers in re-opening packets
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
10,000+
Patients enrolled in patient portal by patient navigators and CHWs
20,000+
Wellness checks performed by CHWs
42,941
Patients screened by patient navigators across 7 emergency departments and 1 inpatient unit
87%
Percentage of 7,187 patients without a primary care physician who were connected to one upon hospital discharge
708
Adults and children enrolled in CHW programs
334
One-on-one CHW-patient sessions
Key Accomplishments
• Expanded Patient Navigator and CHW models to NewYork-Presbyterian/Weill
Cornell Medical Center, NewYork-
Presbyterian 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.
• 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.
60
People attending three diabetes and two asthma workshops
Choosing Healthy & Active Lifestyles for Kids (CHALK)
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. Number of People Reached
34,410
Total individuals reached in 2020, including:
21,994
People through Food FARMacia/FARMacy
10,650
through mini-grant projects
728
through CHALK school partnerships
Learn More
717
through Fruit & Vegetable Prescription
160
Youth Market farm stand customers helped by 19 interns
128
Community leaders
14
Medical residents
1,289
People attending 53 workshops and meetings
• 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 high- risk 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.
Number of People Reached
Key Accomplishments
1,418
People served in 2020
845
Attendees at 26 Zoom presentations
• 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
Do we have NYP outreach photos with masks
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.
Number of People Reached
1,000+
Community members vaccinated against seasonal flu
270
Adults vaccinated against COVID-19 at 6-week Armory pop-up clinic
100
Children received COVID-19 vaccine at Armory and Pediatrics 2000 pop-up clinics
Key Accomplishments
• Distribution of re-opening packet items, including 20,000 facemasks, face shields, and no-touch thermometers.
• 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.
• Vaccination services have expanded through via Columbia University’s mobile medical unit.
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.
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.
