A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
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Innovations In Care
By J. Emilio Carrillo, Nida Shabbir Shekhani, Emme Levin Deland, Elaine M. Fleck, Jaclyn Mucaria,
Robert Guimento, Steven Kaplan, William A. Polf, Victor A. Carrillo, Herbert Pardes, and Steven J. Corwin doi: 10.1377/hlthaff.2011.0635
HEALTH AFFAIRS 30,
NO. 10 (2011): –
A Regional Health Collaborative ©2011 Project HOPE—
The People-to-People Health
Foundation, Inc.
Formed By NewYork-Presbyterian
Aims To Improve The Health Of A
Largely Hispanic Community
J. Emilio Carrillo (ecarrill@
ABSTRACT Communities of poor, low-income immigrants with limited nyp.org) is vice president of
community health at
English proficiency and disproportionate health burdens pose unique NewYork-Presbyterian
challenges to health providers and policy makers. NewYork-Presbyterian Hospital and an associate
professor at Weill Cornell
Hospital developed the Regional Health Collaborative, a population-based Medical College, in New York
health care model to improve the health of the residents of Washington City.
Heights–Inwood. This area is a predominantly Hispanic community in Nida Shabbir Shekhani is a
New York City with high rates of asthma, diabetes, heart disease, and manager in the Office of
Strategy at NewYork-
depression. NewYork-Presbyterian created an integrated network of Presbyterian Hospital.
patient-centered medical homes to form a “medical village” linked to
Emme Levin Deland is senior
other providers and community-based resources. The initiative set out to vice president for strategy at
document the priority health needs of the community, target high- NewYork-Presbyterian
Hospital.
prevalence conditions, improve cultural competence among providers,
and introduce integrated information systems across care sites. The first Elaine M. Fleck is an
associate clinical professor of
six months of the program demonstrated a significant 9.2 percent decline medicine in the Ambulatory
in emergency department visits for ambulatory care–sensitive conditions Care Network of NewYork-
Presbyterian/Columbia, in New
and a 5.8 percent decrease in hospitalizations that was not statistically York City.
significant. This initiative offers a model for other urban academic
Jaclyn Mucaria is senior vice
medical centers to better serve populations facing social and cultural president for ambulatory care
barriers to care. and patient-centered services
at NewYork-Presbyterian
Hospital.
Robert Guimento is vice
president for ambulatory care
A
population-based model of health meet the documented health needs of the local at NewYork-Presbyterian
and health care encompasses the community by incorporating cultural compe- Hospital.
ability to assess the health needs tency, using information systems such as elec-
Steven Kaplan is the chief
of a specific population; implement tronic health records and disease registries, and medical director and quality
and evaluate interventions to im- coordinating care across the continuum. The col- and patient safety officer for
prove that population’s health; and provide care laborative encompasses the entire neighbor- ambulatory care at NewYork-
for individual patients in the context of the pop- hood of Washington Heights–Inwood, in upper Presbyterian Hospital.
ulation’s culture, health status, and health Manhattan, to help improve the health of the
William A. Polf is senior vice
needs.1 NewYork-Presbyterian Hospital, in asso- community by reducing health disparities at president for external
ciation with the Columbia University Medical both the individual and population levels. The relations for NewYork-
Center, has developed a population-based, col- goal is to uniformly enhance and align the health Presbyterian Hospital.
laborative model of regional health planning and care systems throughout the neighborhood to
Victor A. Carrillo is the
care coordination designed to measurably im- improve overall access and quality for the entire director of community health
prove health and reduce disparities. population. development at NewYork-
This model, called the NewYork-Presbyterian In 2008—recognizing that the residents in its Presbyterian Hospital.
Regional Health Collaborative, aligns services to community were experiencing gaps in care and
O c to b e r 2 0 1 1 30:10 H e a lt h A f fai r s 1
Innovations In Care
unmet needs in the context of escalating health The Community According to information
Herbert Pardes is executive costs—NewYork-Presbyterian initiated a major from the New York State Department of Health,
vice chairman of the board of
trustees of NewYork-
review of the health care delivery model. The goal NewYork-Presbyterian serves more than 60 per-
Presbyterian Hospital. was to create a system of care modeled on the cent of the 270,000 residents of Washington
concept of population-based health. The hospital Heights–Inwood, a community geographically
Steven J. Corwin is chief wanted the system to meet identified needs of the bounded by the Hudson and Harlem Rivers.
executive officer of NewYork-
Presbyterian Hospital.
community; improve access to care; and coordi- Most of the residents are poor, Spanish-speaking
nate care for each patient, wherever he or she immigrants who face socioeconomic and health
received care. disparities compared to residents of other parts
The hospital reviewed the services it provided of Manhattan and New York City (Exhibit 2).3–5
and conducted a formal health needs assessment Consequently, taking the residents’ culture, lan-
of the community, using existing health and cen- guage, and health literacy into account plays an
sus data and feedback from community groups, important role in efforts to meet health needs
staff physicians and nurses, and groups of physi- and reduce health disparities in this community.
cians unaffiliated with NewYork-Presbyterian.
The hospital and Columbia University Medical
Center developed a rational, coordinated system Study Data And Methods
to deliver care to the community and agreed to Gathering Information As noted above, in
monitor progress through measurable out- 2008 NewYork-Presbyterian completed a com-
comes. The transformed system launched in Oc- prehensive qualitative and quantitative commu-
tober 2010. nity health needs assessment, which updated a
study conducted in 2006.5,6 The new study ana-
lyzed structural, cognitive, and health care ac-
Background cess barriers related to health knowledge among
The Hospital NewYork-Presbyterian Hospital is community residents, as well as cross-cultural
a 2,278-bed academic medical center that pro- communication needs among community resi-
vides patient care, teaching, research, and com- dents and providers.7 Data were obtained from
munity service to a large and diverse population the Census Bureau, the New York City Depart-
in New York City. It is the teaching hospital for ment of Health and Mental Health, and existing
two major universities, Columbia University Col- studies and surveys. Focus groups and interviews
lege of Physicians and Surgeons and Weill Cor- with key informants—including members of
nell Medical College. The hospital’s attending existing community- and faith-based groups—
physicians are employed directly by the two provided input on the residents’ perceptions of
medical schools. NewYork-Presbyterian Hospi- their health needs.
tal’s facilities are spread across five campuses These analyses identified prevalent chronic
in the New York City area. diseases and needed preventive services. The re-
Although much of the discussion around na- sult was clinical and population health protocols
tional health care reform has focused on features that are consistent with nationally recognized
of integrated delivery systems—as exemplified evidence-based standards and guidelines.
by Mayo Clinic, Geisinger Health System, and The Collaborative The NewYork-Presby-
Kaiser Permanente—the great majority of hospi- terian Regional Health Collaborative is an on-
tals in the United States are not organized as going effort that began in 2008 and has gone
integrated systems. Most traditional academic through four developmental phases. Phase 1
medical centers, like NewYork-Presbyterian, lasted one year and involved more than 140
serve the complex needs of people living in their multidisciplinary participants at NewYork-Pres-
service areas by providing care through a hospi- byterian Hospital, Columbia University, and two
tal and several off-site clinics. Many patients organizations of independent community physi-
use hospitals’ emergency departments for rou- cians. Together these organizations developed
tine care. recommendations based on health needs, access
In 2010 NewYork-Presbyterian provided care barriers, and structural challenges and identi-
in 1.8 million outpatient visits and discharged fied key areas of improvement that the collabo-
more than 117,000 inpatients. More than 40 per- rative would focus on. The targeted areas were
cent of the outpatient visits came through the cultural competency, information technology,
Ambulatory Care Network, which includes the access to care, and the patient-centered medical
hospital and seven stand-alone community home.
health center practices in the Washington In phase 2, which lasted six months, the
Heights–Inwood area. The clinics treat a pre- groups developed program recommendations,
dominantly Hispanic population with public in- defined resource and cost challenges, and iden-
surance (Exhibit 1).2 tified initial strategies for implementation. Rec-
2 Health A ffairs O c to b er 2 0 1 1 30:10
ognizing that access to care was a recurring Exhibit 1
theme, the groups recommended developing
Demographic Characteristics Of Ambulatory Care Network Patients At NewYork-
a patient-centered medical home model at New Presbyterian Hospital, 2008
York-Presbyterian.
Implementation began during 2010, in phase Characteristic Percent
3, as process and outcome measures and emer- Race/ethnicity
gency department and inpatient hospital utiliza- Hispanic 68
tion metrics were established to monitor and Black 13
track progress. Phase 4 began in 2011, with Non-Hispanic white 8
Other 11
the goals of providing complete care co-
11
ordination across the continuum of services
Payer
and supporting the conversion of community
Medicaid 60
physician practices into patient-centered medi- Medicare 18
cal homes. This phase is expected to last well Self-pay 11
into 2012. Private insurance 6
Other 5
Strategies And Programs
SOURCE Note 3 in text.
Four multiyear strategies were formulated to ad-
dress the findings of the 2008 study, as follows:
establishing patient-centered medical homes;
exchanging health information; implementing ogy, nursing, quality, and strategy depart-
a targeted care intervention; and creating a ments—met for eight months to lead the imple-
“medical village”—or interlinked medical homes mentation of the patient-centered medical home
connected to other health care providers, such as model across the network of clinics. The first
hospitals, as well as additional community re- step was to design and integrate information
sources, such as home care providers. The strat- technology dashboards with up-to-date patient
egies are discussed below. information summaries and a registry—an ag-
Establishing Patient-Centered Medical gregate clinical data repository that allows for
Homes trend analysis and data reporting—into clini-
▸▸ TRANSFORMING CLINICS INTO MEDICAL cians’ work flows.
HOMES : Based on recommendations from Next, patient flow within each clinic and be-
phases 1 and 2 of the collaborative, NewYork- tween centers of care was redesigned to accom-
Presbyterian adopted the National Committee modate a patient-centered approach that incor-
for Quality Assurance’s patient-centered medical porated disease and population management
home model8 for the Ambulatory Care Network
practices and school-based health centers. The
Exhibit 2
yearlong implementation phase—phase 3—in-
cluded a site-specific analysis of the gaps in care Demographic Characteristics Of Residents Of Washington Heights–Inwood And New York
at each primary care clinic in the Ambulatory City, 2000
Care Network. Key internal and external stake-
Washington Heights–
holders—such as hospital leaders, students from Characteristic Inwood New York City
Columbia’s Mailman School of Public Health, Race/ethnicity
and members of the community—conducted Hispanic 76% 27%
the analyses, which also assessed each clinic’s White non-Hispanic 14 35
readiness to meet National Committee for Qual- Black/African American non-Hispanic 8 24
ity Assurance standards for becoming a patient- Asian/Pacific Islander 2 10
centered medical home. Literacy and education
Diabetes mellitus, congestive heart failure, Born outside United States 50 36
asthma, and depression were identified as the Speak Spanish at home 62 48
four conditions to be targeted during the first Less than 9th grade educationa 23 10
stage of implementing the patient-centered Income
medical home model. These four were chosen Median household income $28,865 $38,293
based on the 2008 health needs assessment Unemployment rate 14.5% 9.6%
Percent with household income below
and the documented prevalence of the condi-
federal poverty level 30 21
tions at each clinic.
A multidisciplinary group of approximately
fifteen hospital leaders—including physicians SOURCES Notes 6 and 7 in text. NOTES Not all percentages sum to 100 because of rounding. New York
and staff members from information technol- City includes Washington Heights–Inwood. aFor those over age twenty-five.
October 2 011 3 0:10 H e a lt h A f fai r s 3
Innovations In Care
strategies. Multidisciplinary care teams were es- framework and seven domains of cultural com-
tablished, and all team members were trained in petency guided the programmatic efforts and led
cultural competency and the use of the new elec- to employing bilingual and bicultural commu-
tronic dashboards and registry. nity health workers and “navigators” of the
All patients with diabetes, asthma, congestive health system to help provide culturally compe-
heart failure, or depression were automatically tent care.9
entered into a disease registry and were followed NewYork-Presbyterian implemented a four-
longitudinally in accordance with evidence- hour training program that used a skills-based
based clinical guidelines. Depression screening and patient-based approach, aimed at building a
was highlighted and integrated into the disease workforce that could address the linguistic, cul-
registry. Patient education was expanded and tural, and health literacy needs of patients.10 As
targeted according to the clinical severity of each of May 2011 approximately 1,100 employees in
patient’s condition. the emergency department and Ambulatory Care
▸▸ THE MEDICAL HOME DESIGNATION : The Na- Network had received this training.
tional Committee for Quality Assurance has des- The hospital also set up an Office of Care Man-
ignated NewYork-Presbyterian’s seven commu- agement—initially focused on managing the four
nity-based ambulatory care centers as level 3 targeted conditions—where culturally compe-
patient-centered medical homes. This designa- tent nursing staff guided patients across inpa-
tion is the highest level of patient-centered medi- tient and outpatient settings and oversaw their
cal homes and is based on specific criteria that transitions of care. This office contacts patients
reflect the organization’s evidence-based and co- who are admitted to NewYork-Presbyterian and
ordinated primary care patient-centered medical makes follow-up appointments for them at their
home services.8 Another eight Washington patient-centered medical homes. Care managers
Heights–Inwood school-based health centers also follow the disease registry in order to iden-
are preparing to apply for this designation. New tify adverse patterns of utilization and clinical
York-Presbyterian is one of the very few US aca- indicators—such as repeat visits to the emer-
demic medical centers to have large networks of gency department, underuse of hemoglobin
level 3 patient-centered medical homes—an A1c diabetes tests, or abnormally high values
achievement emblematic of the high-quality care of hemoglobin A1c—and intervene as appro-
provided to the Washington Heights–Inwood priate.
community. Exchanging Health Information Informa-
The complete set of patient-centered medical tion technology solutions have included the de-
home services became fully operational at all velopment of a personal health record for each
seven clinics October 4, 2010. This is considered patient, patient-specific disease dashboards, and
the “patient-centered medical home initiation a population-based disease registry. The per-
date”—the time when patients had access to sonal health record allows patients to view their
the enhanced and coordinated services of the medical records and access medical information
patient-centered medical home. on any electronic device that connects to the
▸▸ RELATED GOALS : Improving access was Internet. The disease dashboards automatically
identified as a major need, so several initiatives pull data such as critical laboratory and clinical
targeted this. The existing decentralized call cen- values, inpatient admissions, emergency depart-
ters where patients scheduled appointments, ment visits, and past clinic visits from NewYork-
learned test results, and received follow-up in- Presbyterian’s information technology systems,
formation were transformed to a centralized including the electronic health record, clinical
contact center for information and appointment labs, and patient registration systems.
scheduling. Over a five-month period, the num- These dashboards give patient care teams a
ber of repeat calls from patients fell because ser- longitudinal snapshot of an individual patient
vice was improved and more problems were re- over time. They also alert clinicians who are car-
solved in initial calls. NewYork-Presbyterian ing for a patient when examinations, tests, or
worked with community health workers to iden- screenings are pending or overdue, thus ensur-
tify and communicate with people who might be ing timely and appropriate evidence-based thera-
eligible for, but not enrolled in, the Children’s peutic and preventive interventions.
Health Insurance Program or Medicaid, or who The same electronic health record is used
might not be receiving services for which they throughout the Ambulatory Care Network and
were eligible. the hospital, allowing for a seamless flow of in-
Another goal of the initiative was to improve formation across transitions of care. There are
cultural competency, specifically across the Am- electronic population-based disease dashboards
bulatory Care Network and in the emergency for all ambulatory care patients with a primary or
department. The 2009 National Quality Forum secondary diagnosis of diabetes mellitus,
4 Health Affairs Octo ber 2 011 3 0:10
asthma, congestive heart failure, or a combina- sitions, matching patients to a patient-centered
tion of these three targeted conditions who vis- medical home, and other care management strat-
ited one of the seven ambulatory care clinics on egies, many of which are being implemented
or after January 1, 2010. Depression screening through the NewYork-Presbyterian Regional
has been incorporated into all three disease Health Collaborative.12
dashboards and the disease registry to facilitate Consequently, the targeted care intervention
treatment and care management. A comprehen- focused on the critical hospital-to-home transi-
sive list of data fields for depression is currently tion period to minimize preventable readmis-
under development. sions. The three major elements of the targeted
Between October 2010 and July 2011, 7,731 care intervention model were comprehensive
patients with diabetes, 2,030 with congestive discharge planning, beginning when a patient
heart failure, and 6,550 with asthma were is admitted or arrives at the emergency depart-
added to the registry. The registry captures vital ment; management of transitions of care, includ-
patient-centered medical home and care man- ing a home visit, by a rapid-access team consist-
agement data, such as visits to school-based ing of a nurse practitioner or nurse and
health centers or the emergency department, community health worker; and linking the pa-
inpatient admissions, blood pressure, and levels tient with a patient-centered medical home.
of hemoglobin A1c and low-density lipoproteins The intervention incorporated elements that
(LDL), or “bad” cholesterol. had proved to be effective at NewYork-Presby-
The same protocols, standards, and evaluation terian, such as the use of community health
methodologies are applied to each patient. The workers to help reinforce patient education
registry is built and managed by an information and providing ongoing support and monitoring
technology team at NewYork-Presbyterian, but it after discharge. In addition, the design of the
is designed to allow disease management and intervention adopted key elements of Mary
care teams to study specific populations in the Naylor and colleagues’ transitional care model
database independently. This allows providers to and Eric Coleman and colleagues’ care transi-
identify specific high-risk patients or groups of tions intervention.13,14
patients and proactively direct them to care at the Creating A Medical Village A medical village,
patient-centered medical homes, which avoids according to the NewYork-Presbyterian Region-
unnecessary emergency department visits and al Health Collaborative, is a geographically
hospitalizations. defined community with a number of patient-
Implementing The Targeted Care Inter- centered medical homes linked to other provid-
vention To better meet the needs of chronically ers and community-based resources. The con-
ill adult patients with multiple conditions, the cept has been described previously in the health
initiative also included a targeted care interven- care literature.15
tion that identified the causes of frequent read- The first goal of NewYork-Presbyterian’s medi-
missions and excess use of the emergency de- cal village in Washington Heights–Inwood was
partment. NewYork-Presbyterian conducted a to collaborate with the New York City and State
detailed analysis of historical patient utilization health departments to help local physician prac-
data to assess readmission risk, using a model tices adopt electronic health record systems,
developed by John Billings and colleagues to transform themselves into patient-centered
identify patients at high risk of readmission to medical homes, and establish health informa-
a hospital in the next twelve months.11 tion exchanges. NewYork-Presbyterian has de-
A “root cause analysis” that included chart and veloped a Spanish-language personal health rec-
patient reviews and physician focus groups for a ord16 and is preparing to disseminate it across the
sample of 273 high-use patients identified the medical village in 2012. Multiple community ser-
following as major contributors to costs: multi- vice efforts, described in the online Appendix,17
ple medications; care involving multiple provid- add to the impact of the medical village.
ers, which can be highly fragmented and un-
coordinated; lack of a primary care physician;
and inadequate management of care transitions. Study Results
Further chart analysis indicated that high rates Preliminary utilization results for patients in the
of depression, social problems such as homeless- existing disease registry—for diabetes mellitus,
ness, and cultural and language barriers were congestive heart failure, and asthma—seen dur-
common among frequent users of hospital ing October 2010 indicate decreased emergency
services. department visits for ambulatory care–sensitive
Substantial evidence suggests that there are conditions—diagnoses best dealt with in an out-
opportunities to improve quality and reduce patient setting—and hospitalizations during the
costs by improving the management of care tran- six months after the patient-centered medical
October 2 011 3 0:10 H e a lt h A f fai r s 5
Innovations In Care
Exhibit 3 patients to a cohort based on their first date of
service in one of the seven patient-centered
Emergency Department Use By Patients With Diabetes, Asthma, Or Congestive Heart
Failure, NewYork-Presbyterian Hospital, 2010–11
medical homes on or after October 4, 2010.
The baseline data in Exhibits 3 and 4 include
the number of emergency department visits
and hospitalizations at NewYork-Presbyterian
Emergency department visits within the six months preceding the first pa-
Patients visiting the
tient-centered medical home visit—that is, the
Number of visits or patients
emergency department
start of the cohort time period. Similarly, emer-
gency department visits and hospitalizations
after implementation are those during the six
months after the start of the cohort time period.
The October 2010 cohort (N ¼ 5; 963 pa-
tients) is the first group for which we have six
months of utilization data since the implemen-
tation of the patient-centered medical home
model (Exhibit 5). Baseline utilization for this
group was a mean of 0.59 visits per patient in the
cohort to the emergency department (standard
Baseline
deviation: 1.176; 95% confidence interval: 1.15,
1.21). After implementation of the patient-
SOURCE NewYork-Presbyterian Hospital disease registry. NOTES “Baseline” is utilization in the six centered medical home model, emergency de-
months before October 2010, when the patient-centered medical home model was implemented. partment use for this group decreased 9.2 per-
cent, to a mean of 0.53 visits per patient in
home model was implemented (Exhibits 3 the cohort (standard deviation: 1.083; 95%
and 4). confidence interval: 1.06, 1.11, p ¼ 0:001), a sig-
NewYork-Presbyterian plans to use the pre- nificant difference. During the same period,
vention quality indicators developed by the hospitalizations for the 2010 cohort dropped
Agency for Healthcare Research and Quality18 from 1,503 to 1,416—a 5.8 percent decrease
to measure the quality of care provided by the (p ¼ 0:25), which was not a significant dif-
hospital’s health care system and the overall ference.
health of community residents. The indicators Six months before the patient-centered medi-
are a set of metrics that measure hospital inpa- cal home model was implemented, 1,971 patients
tient admissions for diagnoses of ambulatory in this cohort went to the emergency depart-
care sensitive conditions. Because there is a ment. They made 3,500 visits, or 1.8 visits per
one-year lag in New York State reporting of hos- patient. However, in the six months after imple-
pital discharges, the indicators were not avail- mentation, 143 fewer patients in the cohort
able for this population at the time this article sought emergency department services. In addi-
was written. tion, they made only 1.7 visits per patient during
For the purpose of data analysis, we assigned that period (Exhibits 3 and 4).
Although the early results of the NewYork-
Presbyterian Regional Health Collaborative are
Exhibit 4 promising in terms of the number of visits to the
Hospitalizations Of Patients With Diabetes, Asthma, Or Congestive Heart Failure, NewYork- emergency department, they represent only a
Presbyterian Hospital, 2010–11 six-month period after the implementation of
the patient-centered medical home model. To
verify the collaborative’s success, we will need
Number of visits or patients
Inpatient visits
data from a longer period and from more co-
Number of patients hospitalized
horts. The reductions in hospitalizations and
emergency department use described above cor-
relate with evidence from other patient-centered
medical home interventions.19
Discussion And Conclusion
Baseline Financial Implications The NewYork-Presby-
terian Regional Health Collaborative has re-
SOURCE NewYork-Presbyterian Hospital disease registry. NOTES “Baseline” is hospitalizations in the quired a large commitment of staff resources
six months before October 2010, when the patient-centered medical home model was implemented. and involved the participation of more than
6 H ea lt h A f fai r s October 2 011 3 0:10
140 multidisciplinary staff members at NewYork- Exhibit 5
Presbyterian and Columbia University. Work
Disease Distribution Among Patients With Diabetes, Asthma, Or Congestive Heart Failure,
groups of ten to fifteen staff members at the NewYork-Presbyterian Hospital, 2010
manager or director level were cochaired by a
senior hospital leader and senior physician Disease Number of patients
and met biweekly for the first three phases. Chronic condition (single disease)
NewYork-Presbyterian incurred direct costs of Asthma 1,846
approximately $1.7 million during the first three Congestive heart failure 437
phases of the collaborative. The costs were pri- Diabetes 2,679
marily associated with implementing and main- Chronic conditions (more than one disease)
taining the patient-centered medical homes. Asthma, congestive heart failure 48
Diabetes, asthma 423
However, the hospital expects to receive $3.3 mil-
Diabetes, congestive heart failure 449
lion from New York State’s patient-centered Asthma, diabetes, congestive heart failure 81
medical home revenue enhancement fund. Addi-
tional costs include interpretation services,
which were covered by NewYork-Presbyterian’s SOURCE New York-Presbyterian Hospital disease registry. NOTE Patients are those in the
overall operating budget; and information tech- October 2010 cohort (N ¼ 5; 963), who had their first date of service in one of the seven
patient-centered medical homes between October 4 and October 31, 2010.
nology dashboards and registries, which were
funded by the hospital’s capital budget and
grants. This study could not quantify revenue
losses. an extensive information technology infrastruc-
Challenges Over the course of the NewYork- ture, a wide variety of community-based health
Presbyterian Regional Health Collaborative, the promotion and disease prevention projects, and
hospital faced numerous challenges. For exam- collaboration with the independent local
ple, the initiative was a new concept for the hos- physicians.
pital, involved many key stakeholders, and re- Early results from the first six months after the
quired teamwork and cooperation to go from implementation of the patient-centered medical
formulating strategies to executing them. The home model show a significant reduction in the
hospital’s senior leaders fully supported the col- number of emergency department visits by pa-
laborative. Other staff members’ collaboration tients in the disease registry for diabetes melli-
was obtained by including people from various tus, asthma, and congestive heart failure—three
disciplines across the institution in goal- ambulatory care–sensitive conditions. Although
oriented work groups and training sessions there was also a reduction in the number of hos-
In addition, the patient-centered medical pitalizations, that was not a significant change.
home required a change in clinical practice The NewYork-Presbyterian Regional Health
and behavior. The development and use of dash- Collaborative model is relevant to national
boards and a registry, in particular, involved the health reform efforts because it illustrates an
implementation of multidisciplinary care teams effective means of coordinating care for a poor,
and the institution of “previsit planning.” The immigrant community. The model also included
teams established protocols to review the pa- a targeted care intervention that provided sup-
tient’s care needs according to clinical guidelines port and care coordination to patients who were
before the day of the visit. These new functions considered cost outliers because of disease com-
and roles as well as other changes in the clinical plexity and poor coordination of care by multiple
workflow required training and reinforcement. providers.
Conclusion The NewYork-Presbyterian In sum, the NewYork-Presbyterian Regional
Regional Health Collaborative was designed to Health Collaborative is a population-based
improve health, reduce disparities, and control model that can uniformly improve quality for
costs by providing culturally competent, patient- all patients and reduce disparities by improving
centered care; coordinating population health overall access and quality. The initiative was
services; and targeting high-cost patients for based on the commitment of an academic medi-
case management. The collaborative provides a cal center to better serve urban populations fac-
model for quality health care and cost control to ing social and cultural barriers, and the center’s
the thousands of US hospitals that are not part of leadership and organizational capacity to plan,
integrated health delivery systems. guide, and sustain multifaceted efforts in col-
The collaborative targeted the documented laboration with community-based collaborators.
needs of and health care barriers faced by com- It is replicable and scalable, and it could meet the
munity residents. It combined patient-centered needs of many underserved communities across
medical homes into a medical village. This medi- the United States. ▪
cal village is characterized by care coordination,
O cto b e r 20 1 1 30 : 1 0 H e a lt h A f fai r s 7
Innovations In Care
The authors are grateful for the facilitated the hospital’s involvement Ambulatory Care Network’s medical
contributions of New York State HEAL and helped build bridges with local directors, physicians, nurses, and staff
grants as well as the generosity of community physicians. Rafael Lantigua, have provided tireless and consistent
Pharmaceutical Research and Steven J. Shea, and their Columbia support. The authors thank the Robert
Manufacturers of America and the Heinz University Medical Center colleagues Wood Johnson Foundation and the
Family Philanthropies. The NewYork- have helped build the initiative since its Network for Multicultural Research on
Presbyterian (NYP) Regional Health inception in 2008. Aurelia Boyer, NYP Health and Healthcare for their support,
Collaborative Steering Committee chief information officer, made key mentoring, and inspiration in the
provided consistent support and contributions, as did Tammy Tims, Karen drafting of this article.
invaluable insights throughout. Robert Zaranski, and the rest of the
Kelly, NYP president, championed and information technology team. The NYP
NOTES
1 Contemporary issues in medicine— 7 Carrillo JE, Carrillo V, Perez H, 613–20.
medical informatics and population Salas-Lopez D, Natale-Pereira A, 14 Coleman EA, Parry C, Chalmers S,
health: report II of the Medical Byron AT. Defining and targeting Min SJ. The care transitions inter-
School Objectives Project. Acad Med. health care access barriers. J Health vention: results of a randomized
1999;74:130–41. Care Poor Underserved. 2011;22: controlled trial. Arch Intern Med.
2 Kaplan S. 2009 Ambulatory Care 562–75. 2006;166(17):1822–8.
Network annual quality and safety 8 National Committee for Quality As- 15 Crow C. It takes a village to build a
report. New York (NY): NewYork- surance [home page on the Inter- medical home. Medical Home News.
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8 Health A ffairs O c to b er 2 0 1 1 30:10
ABOUT THE AUTHORS: J. EMILIO CARRILLO, NIDA SHABBIR SHEKHANI,
EMME LEVIN DELAND, ELAINE M. FLECK, JACLYN MUCARIA,
ROBERT GUIMENTO, STEVEN KAPLAN, WILLIAM A. POLF,
VICTOR A. CARRILLO, HERBERT PARDES & STEVEN J. CORWIN
such a high level of support and where she is responsible for
engagement from a provider developing both clinical and
community.” corporate strategic plans. She
Carrillo, who is also an associate obtained a master of business
J. Emilio Carrillo is professor of clinical public health administration degree from
vice president of and clinical medicine at Weill Columbia University’s Graduate
community health Cornell Medical College, has been a School of Business.
at NewYork- senior fellow in residence at the
Presbyterian Robert Wood Johnson Foundation
Hospital.
and coauthored a National Quality
In this month’s Health Affairs, Forum (NQF) paper on measuring
Emilio Carrillo and colleagues at health care disparities. He serves Elaine M. Fleck is
NewYork-Presbyterian Hospital on the NQF Care Coordination an associate clinical
(NYP) in New York City describe Steering Committee. For ten years professor of
the Regional Health Collaborative, Carrillo was on the faculties of medicine at
Harvard’s Medical School and NewYork-
an integrated network of patient-
School of Public Health. He Presbyterian/
centered medical homes that aimed Columbia.
to improve the health of the received medical and master of
residents of a low-income public health degrees from Elaine Fleck is an associate
neighborhood in upper Manhattan. Harvard. clinical professor of medicine in
By undertaking such changes as the Ambulatory Care Network of
targeting high-prevalence NYP/Columbia and director of
conditions and installing internal medicine for the network’s
integrated information systems, the primary care practices. She
collaborative produced a decline in Nida Shabbir received her medical degree from
the use of the emergency Shekhani is a Case Western Reserve University
department in Washington manager in the and her master of public health
Heights–Inwood, a predominantly Office of Strategy degree from the Mailman School.
at NewYork-
Hispanic community, as well as a
Presbyterian
5.8 percent decrease in Hospital.
hospitalizations.
Jaclyn Mucaria is
Carrillo is vice president of Nida Shekhani is a manager in
senior vice
community health at NYP and has the Office of Strategy at NYP. She president for
led the collaborative. “We wanted holds a master’s degree in public ambulatory care
to make an academic medical health policy and management and patient-
center an enabler of health in the from the Mailman School of Public centered services
community by collaborating with Health at Columbia University. at NewYork-
the community,” he says. “You Presbyterian
Hospital.
sometimes hear that working with
health care providers is like Jaclyn Mucaria is senior vice
herding cats, but that wasn’t our president for ambulatory care and
experience. Lots of people came Emme Levin Deland patient-centered services at NYP.
together to make this work. The is senior vice She received her master of public
[information technology] president for administration degree from New
programmers worked directly with strategy at York University.
the doctors to create tools they NewYork-
needed and wanted. The doctors Presbyterian
Hospital.
themselves were very involved in
organizing and changing systems. Emme Deland is senior vice
In fact, I have seldom encountered president for strategy at NYP,
Octo ber 2 011 3 0:10 Health Affa irs 9
Innovations In Care
William Polf is senior vice American Academy of Arts and
president for external relations for Sciences, Pardes has earned the
NYP. He is responsible for Institute of Medicine’s Sarnat
government relations, marketing, International Prize in Mental
Robert Guimento is media and public affairs, Health. He received his medical
vice president for community affairs, grants, and degree from the State University of
ambulatory care at intellectual property. He holds a New York’s College of Medicine.
NewYork-
doctorate in American history from
Presbyterian
Hospital.
Syracuse University.
Robert Guimento is vice
president for ambulatory care at
NYP, where he is responsible for
overseeing financial, operational, Steven J. Corwin is
Victor A. Carrillo is
and strategic initiatives in chief executive
the director of
officer of NewYork-
ambulatory care across all community health
Presbyterian
campuses. He received a master’s development at
Hospital.
degree in health administration NewYork-
from Duke University. Presbyterian Steven Corwin was recently
Hospital.
named chief executive officer of
Victor Carrillo is the director of NewYork-Presbyterian Hospital. A
community health development at cardiologist and internist, he has
Steven Kaplan is
NYP. He holds a master of public been with the hospital since 1979
the chief medical
director and quality administration degree from Pace and joined its management team in
and patient safety University. 1991. During his tenure as the
officer for hospital’s executive vice president
ambulatory care at and chief operating officer, he
NewYork- launched the NewYork-Presbyterian
Presbyterian Regional Health Collaborative.
Hospital.
Corwin obtained his medical degree
Herbert Pardes is
Steven Kaplan is NYP’s chief from Northwestern University.
executive vice chair
medical director and quality and of the board of
patient safety officer for trustees of
ambulatory care. In this role he NewYork-
oversees the clinical operational Presbyterian
Hospital.
activities of fifteen primary care
practices, seven school-based Herbert Pardes is executive vice
health centers, and more than chair of the board of trustees of
sixty-five specialty care practices. A NewYork-Presbyterian Hospital.
practicing physician, he is board Previously he was president and
certified in emergency medicine. chief executive officer of the
Kaplan received his medical degree hospital and the NewYork-
from Weill Cornell Medical College. Presbyterian Healthcare System.
Nationally recognized for his broad
expertise in education, research,
clinical care, and health policy, he
is an ardent advocate of academic
William A. Polf is medical centers, humanistic care,
senior vice and the power of technology and
president for innovation to transform twenty-
external relations first-century medicine.
at NewYork-
An elected member of the
Presbyterian
Hospital.
Institute of Medicine and the
10 Health A ffairs Octo ber 2 011 3 0:10Program or Campaign Goal and Description
Healthy Children in the Regional Effort to Reduce
Heights Obesity in Collaboration with
Local Schools, Elected Officials
and Community Based
Organizations
CHALK(Choosing Healthy Social Marketing Campaign to
and Active Lifestyles for Reduce Childhood Obesity;
Kids) Received Recognition by First
Lady Michelle Obama; supported
by New York City Department of
Health and Mental Hygiene
Healthy Schools – Healthy Exercise and Nutrition School
Families Based in 7 Local Elementary and
Middle Schools; launched with
HRSA support
WIN for Asthma Launched in 2003 with support
from Merck Foundation; Care
Management of Children with
Asthma Using Bi-Cultural
Community Health Workers
Pharmacy Assistance Supports medication purchases
Program for uninsured patients; HRSA
funding
Heart Failure Program Support patients with Heart
(Heinz, PhRMA) Failure with medically trained
Community Health Workers at home
and in the community
Seniors living with Regional program to support
Diabetes (United Hospital seniors with diabetes that links
Fund, Bristol-Meyers with the New York City
Squibb) Department of Aging and
Community-Based Organizations
serving seniors
Building Bridges, Collaborative comprised of
Building Knowledge & Churches, Community Based
Building Health Coalition Organizations, and academic
institutions. Targets diabetes
education and care in the
community. Funded by New York
State Department of Health and
HHS Office of Women’s Health.
Utilizes Community Based
Participatory Research
Methodology.Turn to Us Childhood Violence Prevention,
Derek Jeter Foundation
Single Stop Support entitlement program
enrollment; Governmental Health
Insurance; Robin Hood Foundation
Parish Nursing Program Establishes Wellness Programs in
Churches
Local Industry Health Bodegueros (small food shops);
Promotion and Disease Hair Salons and Barber Shops;
Prevention Programs Livery Cab Drivers; Domestic
Workers
Reach Out and Read Promotes early literacy;
Bilingual and bicultural
School-Based Health The SBHCs operated by the Center
Centers (SBHC) for Community Health and
Education provide a
multidisciplinary service model
that integrates primary care,
mental health counseling and
health education in seven NYP
ACN sites which serve 15
Northern Manhattan intermediate
and high schools. The sites are
located at the George Washington
Educational Campus, the Stitt
Campus, the 143 Campus and the
Inwood Community Campus in
Washington Heights and the Percy
Sutton Campus, Thurgood Marshall
Academy and Promise Academy in
Central Harlem. Student patients
incur no charges for the care
that they receive from licensed
providers.
Table 2: NewYork-Presbyterian Disease Prevention
Initiatives
Source: The Community of Care: Serving the Needs of the
Community, NewYork-Presbyterian Hospital. 2008. Available
from: http://nyp.org/csp.You can also read
