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