ANCHOR (Addressing the Needs of the Community through Holistic, Organizational Relationships) DODI MEYER, MD • Clinical Lead • ddm11@cumc.columbia.edu EVA LERNER, MSW, MPA • Program Manager • evl9023@nyp.org Mission and Goals
Number of People Reached
In 2017, the Division of Community and Population Health received funding from the Center for Medicare and Medicaid Innovation (CMMI) Accountable Health Communities (AHC) program to systematically address patients’ health-related social needs through universal screening and referrals to community service providers. The Division leveraged the grant’s resources to standardize and expand existing Ambulatory Care Network pre-visit screening efforts, transitioning from paper- to tabletbased screening across the following domains: depression, substance use, asthma, housing, food insecurity, transportation, utilities, and domestic violence. In 2018 (the second year of the AHC grant), 3,970 patients in three ambulatory care sites and three emergency departments received tablet-based clinical and/or social needs screening. By screening for healthrelated social needs and clinical risk factors, the Hospital seeks to identify the most vulnerable patients and improve their access to preventive services through social and clinical interventions in the community.
3,970 Number of patients screened 190 Number of high-risk patients accepting navigation services and referred to communitybased organizations
55 Number of patients whose
identified psychosocial needs have been resolved
By screening for health-related social needs and clinical risk factors, the Hospital seeks to identify the most vulnerable patients and improve their access to preventive services through social and clinical interventions in the community. 15
