Division of Community & Population Health 2020 by Torrisi Design Associates

Division of Community and Population Health Report

Table of Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Division of Community and Population Health: Our Mission . . . . . . . . . 2 Community Health Needs Assessment and Community Health Service Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Ambulatory Care Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ambulatory Care Network Nursing . . . . . . . . . . . . . . . . . . . . . . 13 Telehealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Community Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ANCHOR (Addressing the Needs of the Community Through Holistic, Organizational Relationships) . . . . . . . . . . . . . . . . . . . .17 Behavioral Health Clinical Services (Outpatient) . . . . . . . . . . . . . 18 Building Bridges, Knowledge and Health Coalition . . . . . . . . . . . . 20 Center for Community Health and Education . . . . . . . . . . . . . . . 22 CCHE: Family Planning Program and Young Men’s Clinic . . . . . . . . 23 CCHE: School-Based Health Center Program . . . . . . . . . . . . . . . . 24 Compass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Center for Community Health Navigation . . . . . . . . . . . . . . . . . 26 Choosing Healthy & Active Lifestyles for Kids™ (CHALK) . . . . . . . . 28 Community-Based Sexual Health . . . . . . . . . . . . . . . . . . . . . . . 30 Cultural Competency and Health Literacy Workgroup: A Collaboration between the Division and NewYork-Presbyterian Performing Provider System . . . . . . . . . . . 35 Health for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Health Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Healthy City Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Lang Youth Medical Program . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Manhattan Cancer Services Program . . . . . . . . . . . . . . . . . . . . 40 NewYork-Presbyterian Performing Provider System Impact Grants . 42 Outreach Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Reach Out and Read Program . . . . . . . . . . . . . . . . . . . . . . . . . 46 Substance Use Disorder Peer Program . . . . . . . . . . . . . . . . . . . . 47 Summer Youth Experience Program . . . . . . . . . . . . . . . . . . . . . 48 The Family PEACE (Preventing Early Adverse Childhood Experiences) Trauma Treatment Center . . . . . . . . . . . . . . . . . . . 50 Turn 2 Us (T2U) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Waiting Room As a Literacy & Learning Environment (WALLE) . . . . 55 Uptown Hub . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Women, Infants, and Children Program (WIC) . . . . . . . . . . . . . . . 58

Executive Summary Health and wellness start in our homes, neighborhoods, and the communities in which we reside. While health is undoubtedly affected by myriad biological factors, our understanding of the extent to which health is correlated to social factors is ever growing. Consequently, in order to eliminate disparities and provide the best and most equitable care, we need to address specific social aspects of health as much as we work to address medical ones. NewYork-Presbyterian has understood this dynamic for many years. As a result, we developed an expansive portfolio of community programs that direct attention toward prevention and education; address clinical, social, and behavioral needs; and connect community residents to the care they need. The ultimate goal of these programs is to leverage community assets and to work in close partnership with communities to help improve the health outcomes of residents – by connecting them with high-quality healthcare, and encouraging them to become advocates for their own health and their family members’ health. Recently, we have taken a closer look at how social determinants of health affect our communities and have implemented a screening at four outpatient primary care sites in order to identify unmet needs to improve population health. Among more than 24,000 individuals screened, 29 percent screened positive for food insecurity, 25 percent for housing insecurity, 13 percent for transportation needs, eight percent for utility needs, and one percent for domestic violence and safety needs. These findings have helped us improve the way we provide care and prioritize our community offerings. Last year was one of robust evaluation and planning toward strategic growth through our Community Service Plan, enabling us and our collaborators to provide healthcare services, education, and linkage to care to even more individuals in the coming years. Notably, this was the first year the Plan was executed comprehensively across the NewYork-Presbyterian enterprise as one coordinated effort instead of separate hospital efforts. In 2019, NewYork-Presbyterian: • Launched Community Health Worker and ED Patient Navigator programs at NewYork-Presbyterian Brooklyn Methodist and prepared for the expansion of both programs to NewYork-Presbyterian Queens Hospital in 2020. • Continued our work with adolescents through our array of youth programs, such as the Uptown Hub, the Lang Youth Medical Program, NYPeers, and our School-Based Health Centers. • Awarded $1.3 million in Impact Grants to seven community agencies that completed an eight-week competitive request for proposals process. • Implemented Telenutrition at Riverstone Senior Center enabling 99 site-based virtual visits which connected seniors to NewYork-Presbyterian nutritionists. • Collaborated with local health officials, public health experts, and the many communities we reached to perform a Community Health Needs Assessment and create a three-year Community Service Plan for our 10 campuses that described how we will meet the needs of our communities through structured programming. • Expanded our food insecurity work in Northern Manhattan and the Bronx and laid the groundwork for new initiatives in Brooklyn, Lower Manhattan, Queens and Westchester through both the Community Service Plan and a COVID-19 emergency food response. In addition to the community programs listed in this booklet, NewYork-Presbyterian holds more than 200 educational talks and participates in hundreds of events, including health screenings, across our 11.7-millionperson service area. Together, these initiatives have a broad reach and help meet the Hospital’s commitment to improving healthcare outcomes and increasing access in a manner that highlights collaboration and community involvement. We look forward to sharing these efforts with you here, and to continuing to build better health for all New Yorkers. that highlights collaboration and community involvement. We look forward to sharing these efforts with you here, and to continuing to build better health for all New Yorkers.

Division of Community and Population Health: Our Mission

NewYork-Presbyterian’s Division of Community and Population Health collaborates with community, hospital, and academic organizations to improve the health and well-being of children, adolescents, and adults in the communities we serve. The Division conducts a comprehensive community needs assessment 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 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 2

NewYork-Presbyterian has a history of working to enhance the health of individuals in our surrounding communities.

A Long-Term Commitment to Our Neighbors NewYork-Presbyterian has a history of working to enhance the health of individuals in our surrounding communities. As one of the largest academic medical centers in the country, we leverage our patient care, research, and educational resources to address health inequities at the local level. In the Washington Heights and Inwood (WHI) communities, we and our community collaborators have united for more than 30 years to build the infrastructure needed to bolster and maintain vital population health initiatives. We have used this experience to expand our offerings to other communities throughout New York City and Westchester County. Who We Serve The WHI communities are highly diverse. More than 70% of residents identify as Hispanic and have encountered cultural, social, and language obstacles to care. WHI also experiences a disproportionate health burden compared to the rest of New York City. One in three residents lives below the poverty line. Diabetes, asthma, heart failure, depression, and childhood obesity are major health concerns. WHI is a federally designated “empowerment zone,” indicating that it has one of the greatest concentrations of poverty in the United States and is 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 NewYork-Presbyterian/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 is foreign born. 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% do not have health insurance.

Community Health Needs Assessment and Community Health Service Plan

NewYork-Presbyterian (NYP) is deeply committed to the communities in the boroughs of New York City, Westchester County, and the surrounding areas. NewYork-Presbyterian delivers a range of innovative programs and services intended to educate and provide resources to prevent illness, maintain health, and improve the overall well-being of the community. In 2019, NewYork-Presbyterian

completed its triennial Community Health Needs Assessment (CHNA) to understand the needs of local communities and the conditions that influence their well-being, as well as to assemble a three-year plan to enhance community health in areas identified as highdisparity neighborhoods. Governance, Engagement, and Collaboration: The Division of Community & Population Health and the Office of Government & Community Relations partnered to develop an enterprise wide CHNA process to promote community awareness and hospital alignment in order to maximize the impact on those who need it most. A Steering Committee consisting of NewYork-Presbyterian leadership, which included representation across all of our campuses, was key to providing insight and guidance and making decisions that affected the completion of the CHNA.

NewYork-Presbyterian delivers a range of innovative programs and services intended to educate and provide resources to prevent illness, maintain health, and improve the overall well-being of the community. Process: NewYork-Presbyterian obtained broad community input regarding local health needs, including those of medically underserved and low-income populations, through focus groups, questionnaires, and surveys. New York Academy of Medicine helped to conduct the targeted focus groups and questionnaires. Data collection included quantitative data for demographics, socioeconomic status, health, and social determinants, as well as qualitative data from community questionnaires and focus groups, which were analyzed to identify high-disparity communities and develop a prioritization process ensuring integration with the Priority Areas of the 2019-2024 NYS Prevention Agenda. Premier Inc. was engaged to partner with the NewYork-Presbyterian team to complete the needs assessment in a transparent and collaborative manner. Prioritization Method: Premier Inc. customized a prioritization model utilizing the Hanlon Method to quantify and compare indicators and identify significant community needs. The top-quartile high-disparity neighborhood datasets inclusive of social determinants of health, health outcomes, access, and utilization were analyzed to ensure a dynamic model for NewYork-Presbyterian. The model also included qualitative datasets to allow the voice of the community and our internal service line directors and ancillary staff, otherwise referred to as Think Tanks, to play into the top priorities. Prioritized Indicators: The prioritization method allowed the NewYork-Presbyterian team to narrow a vast amount of quantitative and qualitative datasets and define the highest-disparity community and health indicators impacting that community. The top 10 indicators: 1. Binge Drinking 2. Cancer Incidence 3. Hospitalizations: Drug 4. Obesity 5. Diabetes 6. HIV 7. Physical Activity 8. % of adults taking high blood pressure medication 9. Psychiatry 10. Late or No Prenatal Care High-Disparity Communities: High-disparity communities were identified by calculating a needs score consisting of a composite of 29 indicators, carefully selected, across five domains: demographics, income, insurance, access to care, and New York State Department of Health Prevention Agenda Priorities. For NYC, Neighborhood Tabulation Areas were utilized. For geographies outside NYC, a ZIP-code-level Community Need Index was utilized. Overall, the higher-disparity quartiles are illustrated below in red and orange. For NYC, the high-disparity communities that NewYork-Presbyterian identified were Washington Heights, Lower East Side, Crown Heights, and Corona. Outside NYC, the high-disparity communities identified were Mount Vernon and Peekskill. 5

Community Health Needs Assessment and Community Health Service Plan

NEW YORK CITY

NON-NEW YORK CITY

Focused Priorities: The data collection and prioritization allowed NewYork-Presbyterian to identify the highest disparity of need within the communities of highest need and to align initiatives and partnerships to focus efforts and maximize the return to the communities they serve. Based on these findings, the top four priorities for a community service plan are: • Prevention of Communicable Diseases • Mental Health and Substance Use • Women, Infants, and Children • Prevention of Chronic Diseases The focus will not preclude NewYork-Presbyterian from initiatives not related to the focused priorities but allows it to invest in new opportunities of impact.

Preliminary Interventions: Priority Prevent Chronic Diseases

Focus Healthy eating and food security Chronic disease preventative care and management

Promote Healthy Women, Infants & Children

Maternal & Women’s Health

Goals Increase access to healthy and affordable foods and beverages Increase knowledge to support healthy food and beverage choices

Intervention Article 28—School-Based Health Center Obesity prevention program aimed to serve high-risk communities

Increase food security

Address food insecurity and other social determinants of health

Increase use of primary & preventative healthcare services for all women

Article 28—School-Based Health Center—Teen Pregnancy Program

Reduce maternal mortality and morbidity

Develop a two-generation approach for improving maternal child health in primary care & community settings Doula/midwife support for high-risk pregnancies in the prenatal and postpartum period

Promote Well-Being and Prevent Mental & Substance Use Disorders

Prevent Mental and Substance Use Disorders

Prevent underage drinking and excessive alcohol consumption, opioid and other substance misuse, and deaths and suicides

Mental Health First Aid Geriatric Psychiatric TeleHealth Program

Prevent and address adverse childhood experiences Reduce the prevalence of major depressive disorders and mortality gap Prevent Communicable Diseases

HIV & HCV

Increase viral suppression Increase the number of persons treated for HCV

Systemwide HIV and HCV Outreach Dashboard and community navigation program to effect care engagement, HIV viral load suppression, and HCV treatment

Further CHNA Impacts: The comprehensive and collaboration development of this Community Health Needs Assessment has led to the development of new targeted programs at NewYorkPresbyterian. NewYork-Presbyterian took the understandings and conclusions formed from the CHNA to expand programs that were evidence-based or prime for expansion.

Ambulatory Care Network

The Ambulatory Care Network touches all of our communities, making it easier for everyone to access high-quality, affordable, patient-friendly care in their own neighborhoods. NewYork-Presbyterian’s Division of Community and Population Health provides clinical services through its Ambulatory Care Network (ACN), which includes 14 primary care sites, seven schoolbased health centers, 10 mental health school-based programs, and over 35 specialty practices. We serve generations of families from across New York City who represent a wide array of nationalities and ethnic and religious backgrounds. The Ambulatory Care Network touches all of our communities, making it easier for everyone to access high-quality, affordable, patient-friendly care in their own neighborhoods. We provide a broad range of services. When specialized care or hospitalization is required, our compassionate and helpful staff coordinate patients’ needs with the extraordinary range of specialty programs and resources available at NewYorkPresbyterian. All of our Ambulatory Care Network primary care practices are Patient-Centered Medical Homes, where patients receive care from a team of dedicated healthcare providers, led by their primary doctors. With patient participation, the medical team coordinates and manages treatment plans so patients and their families receive the best care. With the support of State funding and generous donors, we have continued to enhance our clinical care by implementing innovative programs targeting specific health needs in the communities we serve. We have embedded these programs seamlessly into our practice operations, and they function in collaboration with our clinical staff to ensure our patients receive the care they need. The following is a description of some of our clinical offerings.

PRIMARY CARE LOCATIONS NewYork-Presbyterian/ Weill Cornell Medical Center Weill Cornell Internal Medicine Associates Wright Center 1484 First Avenue, 1st Floor New York, NY 10075 Irving Sherwood Wright Center on Aging 525 East 68th Street, Payson 2 New York, NY 10065 Weill Cornell Internal Medicine Associates 505 East 70th Street Helmsley Tower, 4th Floor New York, NY 10021 Pediatric Practice 505 East 70th Street Helmsley Tower, 5th Floor New York, NY 10021 Women’s Health Practice 505 East 70th Street Helmsley Tower, 5th Floor New York, NY 10021 The Center for Special Studies Glenn Bernbaum Unit 525 East 68th Street, Baker 24 New York, NY 10065 The Center for Special Studies The Judith Peabody Wellness Center David E. Rogers Unit 53 West 23rd Street, 6th Floor New York, NY 10010

Tobacco Treatment Services Julie Chipman Program Manager chipmaj@nyp.org

PRIMARY CARE LOCATIONS David Albert, DDS, MPH, Clinical Lead daa1@cumc.columbia.edu

Tobacco Treatment Services (TTS) facilitates adoption of tobacco treatment by Ambulatory Care Network and Hospital clinicians. The team — patient navigators and nurse practitioners who are dedicated to TTS or content experts integrating TTS into their primary care roles — has engaged nearly 4,300 ACN patients in tobacco treatment. In 2019, the team trained providers and medical assistants on tobacco treatment and engagement across the ACN. TTS staff organized tabling events across the clinics in November to raise awareness about The Great American Smokeout. The TTS team participated in community activities, including educational workshops, health fairs, and sponsorship of an annual Tobacco Treatment Specialist training for hospital and community-based organizations in the tri-state area. In 2019, the team began a collaboration with the Herbert Irving Comprehensive Cancer Center to expand TTS services.

NewYork-Presbyterian/ Columbia University Irving Medical Center Associates in Internal Medicine (AIM) 622 West 168th Street, 2nd Floor New York, NY 10032 Audubon Practice Obstetrics and Gynecology/Pediatrics 21 Audubon Avenue New York, NY 10032 Broadway Practice 4781-83 Broadway New York, NY 10034 Comprehensive Health Program 180 Fort Washington Ave., 6th Floor New York, NY 10032 Charles B. Rangel Community Health Center 534 West 135th Street New York, NY 10031 Herman “Denny” Farrell, Jr. Community Health Center 610 West 158th Street New York, NY 10032 The Washington Heights Family Health Center 575 West 181st Street New York, NY 10033

Transitions of Care Program Kimberly Rosado, Manager kir9027@nyp.org

Claudia Beck, Clinical Lead cbb9003@nyp.org

The Transitions of Care (ToC) program strengthens continuity of care between NewYorkPresbyterian 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 NewYork-Presbyterian Allen Hospital, Columbia University Irving Medical Center, Weill Cornell Medical Center, and Lower Manhattan Hospital. The goals of the program are to identify and engage Medicaid patients at increased risk for readmission and to provide education for these patients and their caregivers on disease and selfmanagement; facilitate timely follow-up with primary care provider(s); and coordinate medical and social service needs to overcome barriers to safe transitions. Among 30-day care transitions in 2018, 594 patient discharges were reached, and there were 833 highutilizer discharges through the MAX Series at NewYork-Presbyterian/Columbia — a New York State-sponsored initiative to improve care pathways for high utilizers of inpatient care. There was a 4% reduction in the 30-day readmission rate from 2016-17 (40%) to 2018 (36%). The NewYork-Presbyterian/Columbia team expanded on previous MAX Series efforts at NewYork-Presbyterian/Weill Cornell, implementing new assessments by Emergency Department care coordinators and social workers to identify drivers of utilization and establish daily huddles to link patients with various community teams. The ToC team also expanded in October 2018 to include an embedded care coordinator and part-time outreach specialist employed by ACMH, Inc., an agency focused on patients with behavioral health needs. The team continues to include ACMH care coordinators, as well as the addition of a peer specialist from our CBO partner, Services for the Underserved.

Clinical Services: Ambulatory Care Network Ambulatory Care Network Community Practices COLUMBIA UNIVERSITY VOLUME BY PRACTICE – 2019 VISITS PRIMARY CARE

VISITS

VC3 CLINICS

AIM Group

64,965

VC3 - Allergy

Audubon

33,432

VC3 - Ortho

6,685

Broadway

39,671

VC3 - Pediatric Neuro

1,091

20,988

VC3 - Pediatric Ortho

1,022

VC3 - Psychiatry

1,231

Comprehensive Health Care Farrell

19,913

Rangel

19,870

Washington Heights SUBTOTAL PRIMARY CARE SPECIALTY CARE

Audiology

VISITS

733

SUBTOTAL VC3

10,762

33,605

VC10 CLINICS

VISITS

232,444

VC10 - Chest

2,299

VC10 - Neurology

4,145

VISITS

1,258

VC10 - Neurosurgery VC10 - Newborn

503 2,030

Child Advocacy

300

VC10 - Newborn Nutrition

Colposcopy

813

VC10 - Nutrition

1,033

927

Dermatology

10,933

VC10 - Otolaryngology

4,630

Family Planning

24,763

VC10 - Special Gyn

1,086

Ft. Washington Movement Disorder

3,158 18,911

PEACE Program

3,331

Thyroid SUBTOTAL SPECIALTY CARE

16,653

PSYCH CLINICS

Adult Psych

9,656 670

CSS Baker

12,972

CSS Chelsea

15,519

Pediatrics

16,856

OB/GYN

16,174

WCIMA

49,045

WCIMA at Wright

6,430

Wright Center on Aging

9,597

SPECIALTY CARE

VISITS

Adult Dental

7,233

Cardiology

2,459

CSS Dental

1,709

Endocrinology

927

Fracture

899

Hand Surgery

270

Pediatric Dental

3,100

21,345

PFT Lab

SUBTOTAL PSYCH

49,845

74,414 SCHOOL BASED

VISITS

School Based

21,251 172,925 405,369

666

SUBTOTAL SPECIALTY CARE

19,804

TOTAL WEILL CORNELL ACN

146,397

METHADONE

Adult HIV SVC. Adult TOTAL METHADONE TOTAL NUTRITION

ACN-Payor Mix 2019

126,593

SUBTOTAL PRIMARY CARE

VISITS

28,500

TOTAL COLUMBIA UNIVERSITY ACN

VISITS

2,541

Pediatric Psych

TOTAL SPECIALTY CARE

PRIMARY CARE

Neurology

621

Ophthalmology Same Day Access

SUBTOTAL VC10

WEILL CORNELL VOLUME BY PRACTICE 2019 VISITS

VISITS

1,147 27,211 28,358 1,246

Sum of Cases

Medicaid Managed

42%

Medicare Managed

18%

Medicare FFS

14%

Commercial

12%

Medicaid FFS

Self-Pay

Other

AMBULATORY CARE NETWORK NURSING Nurses in NewYork-Presbyterian’s Ambulatory Care Network 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. Empowering patients, families, communities, and colleagues to ensure culturally competent and compassionate care. • Autonomy. Fostering self-directed practice through critical thinking and accountability. • Collaboration. Promoting interprofessional communication and coordination of patientand family-centered care. •E vidence-based practice. Integrating clinical expertise, scientific findings, and patient preferences to improve outcomes. • Professional development. Committing to personal, clinical, and scholarly growth to optimize the patient experience. RNs are certified in their specialties and use the clinical ladder to advance their professional growth, as well as teach nursing staff about various topics to enhance their development and competencies. Advanced practice nurses have their PhDs, DNPs, and Certificates in Mental Health in primary care and other specialties. 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 at the practice and department levels, 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 speeding the ability to meet patient care needs, with the goal of decreasing Emergency Department and walk-in 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.

Clinical Services: Ambulatory Care Network

AMBULATORY CARE NETWORK NURSING continued 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 breast feed and providing education on its importance and health benefits for infants, and providing a baby-friendly environment at practice sites. • Taking active roles in telemedicine at practices where nurses triage patients and assist them through the telehealth process and follow-up. •S upport 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 Centering Pregnancy, which provides new mothers with education and support during pregnancy and the early period after childbirth. This program has resulted in a decrease in low birthweight babies, preterm deliveries, and sexually transmitted diseases and an increase in breastfeeding rates. (For more information, page 26.) Magnet Designation and Journeys In 2019, NewYork-Presbyterian/Weill Cornell achieved the prestigious Magnet® recognition from the American Nurses Credentialing Center. The work to get to this point began years before 2019, with nurses examining data and methods to improve patient outcomes, enhancing communication among nurses, and encouraging nursing engagement through collaborative work, peer review, and ensuring they have a voice to enhance patient care and safety through committees, policy changes, and onsite activities. NewYork-Presbyterian Allen Hospital has begun its Magnet journey to seek this designation. Sharing Research and Expertise Advanced practice nurses are involved in scholarly activities, presenting and publishing their work regionally and nationally on programs such as: • Eating Healthy Living health project • Expedited partner treatment for Chlamydia in female adolescents (poster presentations and peer-reviewed journal articles) • Providing intrauterine devices to adolescents in nontraditional settings (book chapter) • Use of acupressure to treat dysmenorrhea in female adolescents (manuscript in preparation)

PRESENTATIONS BY NURSING • Improving Tobacco Cessation Services in Primary Care: DSRIP Update by Stasi Lubanski, DNP, ANP, CDE, CTTS • Staff Healthy Living Program: Esther Wei, MSN, ANP, CDE; Shahla Morris, RN, MPH, CCRN, CDE; Lucia Hu, RN, MPA; Gabriele Siragusa, RD, CDE; and Christine Tablang, RN, BSN • Imagery & Phlebotomy: A Pilot Study by Christine S. Tablang, BSN, RN-BC • Increasing Influenza Vaccination amongst Vulnerable Pediatric Asthmatics: A pilot quality improvement project by Sloane Zuckerman, BSN, RN, AE-C • American Association of Diabetes conference in Orlando. “Tailoring the Diabetes Regimen: One Size Does Not Fit All” by Mary C. Ballin, GNP-BC, CDE

TELEHEALTH

TELEHEALTH KEY ACCOMPLISHMENTS

Elaine Fleck, MD, Medical Director fleckel@nyp.org

Tatiana Blue, Innovation Manager tab2013@nyp.org

Alpa Prashar, Director alp9048@nyp.org

Jenna Zitaner, Project Lead jez9029@nyp.org

Mission and Goals Since 2018, the Division of Community and Population Health has been integrating virtual care delivery throughout our primary care specialty care, and behavioral health offerings. Building on NYP OnDemand, NewYork-Presbyterian’s comprehensive digital health service platform, the Division is using telehealth services and digital technology to support its mission of improving health and well-being in the communities we serve by: • Increasing access to high-quality primary care, specialty care, and behavioral health services • Improving chronic disease management and outcomes in people with chronic conditions (such as chronic obstructive pulmonary disease, diabetes, and high blood pressure) • Supporting digital health literacy within our community By shifting the model of care delivery, the Division is looking to increase incremental access and meet our patients where they are — in our practice sites, in their homes, and in the community. Number of People Reached January – December 2019: 24,570 telehealth encounters

Access Improvement Highlights Program

In-Person Wait Time

Telehealth Wait Time

Primary Care

5 weeks

Immediate Availibility

Neurology

8 weeks

24 hours

Dermatology

4 weeks

Telepharmacy

7 days

Behavioral Health Management

3 months

➔

10 minutes

• Expanded same-day consultations for primary care patients to three ACN practices, allowing patients with non-emergency needs to walk in without an appointment and see a doctor immediately. • Introduced remote patient monitoring for hypertension patients and Type 2 diabetic pregnant women. • Established telepsychiatry services for depression at all sites that treat pregnant and postpartum women. • Awarded first place in the American Hospital Association Innovation Challenge, recognizing our use of telehealth to target social determinants of health for pediatric and maternal care. • Merged telepharmacy into teleneurology consultations to educate patients about their care plans and improve treatment compliance. • Expanded same-day dermatology consultations to all primary care practices so that primary care doctors can refer patients to a dermatologist via telehealth. • Launched community based nutrition services in partnership with local senior centers, providing members access to group nutrition sessions and individual consultations.

24 hours 3 weeks

Community Health Programs

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

In 2017, the Division of Community and Population Health was awarded the Accountable Health Communities grant from the Center for Medicare & Medicaid Innovation to address patients’ health-related social needs through universal screening and referrals to community service providers. Throughout 2019, 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, NowPow and Epic, to build screening and navigation workflows directly into the new EMR. Eight full-time Patient Navigators and 124 interns screened 21,306 patients across the following domains: depression, substance use, asthma, housing, food insecurity, transportation, utilities, and domestic violence. The most common social needs were food insecurity (28 percent) and housing (24 percent). A total of 1,036 high-risk patients received navigation services to community-based resources, and 833 psychosocial needs were resolved.

Number of People Reached

21,306

Number of patients screened.

1,036 Number of high-risk patients accepting navigation services and referred to communitybased organizations. 833 Number of psychosocial needs resolved (patients can have more than one need in different stages of resolution.

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. 17

Community Health Programs

Behavioral Health Clinical Services (Outpatient) ERICA M. CHIN, PHD • Director of Psychology • erc9027@nyp.org x WARREN Y.K. NG, MD, MPH • Medical Director • ywn9001@nyp.org x WHITNEY ALE • MPH Practice Administrator • wva9001@nyp.org 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. Innovations include providing individual and group-based telemental health services to the community. Behavioral Health Clinical Services comprise two comprehensive clinical components: Child/Adolescent and Adult clinical services. CHILD/ADOLESCENT BEHAVIORAL HEALTH SERVICES

Community and Acute Child and Adolescent Outpatient Services Liora Hoffman, PhD Program Clinical Director

impact. Comprehensive clinical services create a spectrum of mental healthcare reaching from homes and schools in the community to primary care and hospitalbased 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

2,100+

hildren and adolescents C receiving mental health care

33,000+ Child and adolescent mental health visits 2,000+ Youth impacted by intensive school-based prevention interventions Key Accomplishments

Denise Leung, MD Program Medical Director Special Needs Clinic and School-Based Mental Health Program Alexandra Canetti, MD Program Medical Director Jennifer Cruz, PhD Program Clinical Director Mission and Goals

Child/Adolescent Psychiatric Services provides the highest-quality community-based mental health care to our youth and their families. Mental health needs influence medical, social, educational, and occupational outcomes for families in our community; our care promotes health and wellness. Direct clinical care serves over 2,000 families annually, with prevention interventions having a wide-reaching 18

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 NewYorkPresbyterian 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 highest need.

• The School-Based Mental Health Program provides psychological evaluation, treatment, consultation, and workshops to children (ages four-13, grades pre-K through eight), families, and school staff— coordinating with our Home-Based Crisis Intervention Teams to ensure care is integrated from home to school for children with the highest need. • The innovative Integrated Mental Health Program, embedded within four community pediatric primary care ACN clinics, provides psychiatric and psychological services. Specialty programs meet specific care needs for youth and families and 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 offers comprehensive neuropsychological evaluations and advocacy for underserved children with learning disorders and serves over 300 youth per year. • The NewYork-Presbyterian Youth Anxiety Center serves emerging adults in need of targeted mental healthcare. The programs support and empower young adults in collaboration with communitybased 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 communitybased mental healthcare.

ADULT OUTPATIENT BEHAVIORAL HEALTH SERVICES

Renu Culas, MD Program Medical Director Mission and Goals

The Adult Outpatient Psychiatry Clinic provides culturally and linguistically responsive mental healthcare, 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. Number of People Reached

1,400+

dults who received mental A health care

25,000+ Adult mental health visits Key Accomplishments

Specialty programming offered in our clinic includes:

phone coaching, consultation team, and case management) in Spanish and English, delivered by psychologists, psychiatrists, social workers, and substance abuse counselors. • Clinic-based crisis intervention services from social work and psychiatric providers to identify patients requiring more intensive coordination of care due to the complexity of their care needs. The team also provides real-time linkage to long-term mental healthcare. • Specialty treatment services for individuals and family members affected by HIV, LGBTQ individuals, people with co-existing mental health and substance abuse disorders (MICA services), monolingual Spanishspeaking patients, and pregnant and postpartum women. • Training 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 NewYorkPresbyterian 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.

BEHAVIORAL HEALTH (BH) CRISIS PROGRAM

Heather Straccia MD, CT Clinical Lead Warren Y. K. Ng, MD, MPH Medical Director, Outpatient Behavioral Health Supported by DSRIP initiatives, the BH Community Crisis Stabilization Program transformed our outpatient psychiatric services by developing a psychiatric service embedded within the community: a Critical Time Intervention (CTI) team. The CTI program targets patients with comorbid behavioral health, substance use, and social determinants of health needs by providing rapid triage, assessment, and linkage to comprehensive services, utilizing a multidisciplinary team in partnership with community-based organizations and providers. The CTI team assists patients in potentially destabilizing periods of transition as well as provides intensive behavioral health services in the community for three to nine months. Most patients have co-occurring substance use issues, chronic medical conditions, unstable housing, and psychosocial stressors. Since the program began in 2017, the CTI team has cared for 174 patients, and the 30-day hospital readmission rate has declined from 50 percent to 19 percent. Patients with chronic medical conditions, including those that had not been effectively treated, have received extensive health management and linkage to appropriate medical care.

•D ialectical Behavior Treatment (DBT) program, offering all five modes of DBT (individual therapy, skills group, 19

Community Health Programs

Building Bridges, Knowledge and Health MONICA HIDALGO • Manager • moh9017@nyp.org x DEBORAH ACEVEDO, RN • Nurse Coordinator • acevedd@nyp.org KAYLEEN GARCIA • Program Coordinator • kag9132@nyp.org Mission and Goals

Number of People Reached

Building Bridges, Knowledge and Health (BBKH) is a coalition of faithand community-based organizations that collaborate to decrease racial/ ethnic health disparities and enhance the health and well-being of residents of Northern Manhattan, Harlem, and the Bronx. Faith-based members are a valuable resource for the BBKH coalition. They work as conduits of good health to respond to community health needs and implement interventions that achieve meaningful and lasting results.

4,000

NewYork-Presbyterian’s Outreach team has collaborated with BBKH member churches—some include the Van Nest Assembly of God, Convent Avenue Baptist Church, the Narrow Door Church, Christ Church, and Grace Tabernacle—to provide free vision and blood pressure screenings and instruction in hands-only CPR training. We have also collaborated with the Weill Cornell HeartSmarts program to provide two 12-week programs to two churches. One of our BBKH Spanish members received program training and was able to provide the first-ever HeartSmarts class in Spanish to the Washington Heights community. Both co-hosts saw lasting lifestyle changes and marked improvements in weight loss, BMI, BP, A1C, and waist circumference.

Key Accomplishments

In 2019, NewYork-Presbyterian, in partnership with BBKH program members, again supported New York City’s First Lady Chirlane McCray’s ThriveNYC initiative by offering Mental Health First Aid trainings to 200 community members. We hosted our Third Annual Clergy Summit, where nearly 100 faith- and community-based organizations participated in learning more on the topic of “Homelessness: Learning From the Faith Community.” Ydanis Rodriguez, NYC Council member for the 10th District, spoke about homelessness in our community, and Patricia Hernandez, LCSW, spoke on the housing crisis. Panelists from around the city’s faithbased community presented their programs that address the needs of the homeless. Each year, BBKH partners with NewYorkPresbyterian’s Outreach Program to host Hope Day in the Bronx, attracting over 1,500 city residents and providing access to free health screenings, information, counseling, resources, medical referrals, and health insurance information. Through telephone followup, participants are connected to primary care, and health counseling is reinforced. At Hope Day in the Bronx, we team up

with a dozen churches that jointly help carry out this event. Our involvement in the faith-based community also includes work that benefits the homeless population: • Two health luncheons in the Bowery Mission Women’s and Men’s Residency Centers. • Homeless Outreach “Don’t Walk By” events (every Saturday in February)—in partnership with the Salvation Army, New York City Rescue Mission, and the Bowery Mission. We provide funding for backpacks, as well as medical care during the events. NewYork-Presbyterian sent RNs and other volunteers to both the 2019 and the 2020 events. We also donated backpacks for the homeless guests at the events. • Health education and screenings, in collaboration with local churches and community organizations. In 2019, we continued to partner with the Church of the Epiphany to provide monthly blood pressure and HIV screenings and counseling at its weekly soup kitchen, which provides meals to guests—mostly adults who are homeless or food insecure. We were able to award a guest a free digital blood pressure machine because of the improvement in blood pressure and weight loss. In December, in partnership with staff from the Milstein community outreach committee, we provided free reading glasses, thermals, and coats to homeless shelters. We also contributed thermals and coats to homeless youth who participate in the Drop-In Program at the Dominican Women’s Development

Center. Health screenings and coats were also provided to the Washington Heights women’s shelter, in collaboration with nurses from Milstein Hospital. During the height of the pandemic, we had to think of new ways to continue providing support to BBKH members. In April 2020, we held our first-ever virtual monthly BBKH meeting, in which we were able to increase core member attendance by nearly 150 percent. Each meeting was tailored to addressing current public health emergency concerns and resources that would continue aiding in the education of COVID-19 and how to best care for ourselves and those around us.

In June 2020, we hosted a two-part virtual series in which a community member discussed “Church Readiness in the Midst of COVID-19,” a workshop focusing on the church’s role as a pillar in the community during pandemic recovery and planning. We engaged about 25-30 BBKH members, and all had their own scenarios to share and questions to ask. As a result of this series, we have partnered with a BBKH member to compile a virtual directory that will serve as a resource to our communities, listing congregations that provide virtual services with details of their meeting times and links/ platforms.

Community Health Programs

Center for Community Health and Education (CCHE) JANET GARTH, MPH • Manager • jag9007@nyp.org

Mission and Goals

The Center for Community Health and Education (CCHE), in partnership with Columbia University Irving Medical Center, has provided comprehensive medical, mental health, and health education services to adolescents and adults in Northern Manhattan and the Bronx for over 40 years. We advance service innovations through community partnerships, research, and teaching. CCHE comprises: • The Family Planning Practice and its co-located Young Men’s Clinic. • Seven School-Based Health Centers serving 23 New York City intermediate and high schools. • NYPeers, a teen peer education and leadership program. • Community- and classroom-based health education and adolescent pregnancy prevention programming. Our goals are to: • Provide comprehensive women’s and young men’s healthcare services. • Provide primary healthcare services to adolescents that include medical, mental health, and health education. • Prevent early childbearing and delay initiation of first intercourse . • Increase the use of effective contraception among sexually active men and women who are not seeking pregnancy.

• Reduce the transmission of sexually transmitted infections, including HIV. • Support the healthy transition from adolescence to adulthood. CCHE collaborates with local New York City public schools; the Columbia University Irving Medical Center Departments of Population and Family

Health, Pediatrics, Obstetrics and Gynecology, Family Medicine, Psychiatry, and Ophthalmology; and the Columbia University College of Dental Medicine, as well as many community-based organizations.

CCHE: Family Planning Program and Young Men’s Clinic MADELINE OLMEDA • Practice Administrator • mao9144@nyp.org x DAVID BELL, MD • Medical Director, Young Men’s Clinic • dlb54@cumc.columbia.edu x ANA CEPIN, MD • Medical Director, Family Planning Program • ac272@cumc.columbia.edu Mission and Goals

Number of People Reached

The Family Planning Program provides confidential and comprehensive medical, sexual health, mental health, and health education services to adolescents, women, and men to:

15,000

• Assist individuals in determining the number and spacing of their children.

2,000 Teen health education workshops

• Increase use of effective contraception among sexually active men and women who are not seeking pregnancy.

2,000 Benefits and supportive services enrollment

• Prevent teen pregnancy and early childbearing. • Reduce the transmission of sexually transmitted infections and HIV. • Facilitate entry into early prenatal care for pregnant women. • Provide preventive preconception health services, such as breast and cervical cancer screening. The Family Planning Center (FPC) and Young Men’s Clinic have provided family planning and adolescent pregnancy prevention services to the Washington Heights/Inwood community since 1976.

Total patients annually

1,500 Adolescent patients 800 Community health education workshops

Key Accomplishments

• Contraceptive best practices. T. The FPC has been a national leader in service-based research for women’s reproductive health, and several contraceptive best practices pioneered at the FPC have significantly improved contraceptive initiation and compliance nationally. • TELEMEDICINE. We are able to use telemedicine to provide contraceptive counseling and initiation, as well as pregnancy options counseling and referral. Patients can also receive diagnosis and treatment for common conditions such as vaginal infections and urinary tract infections. Many patients are able to receive the care they need without having to leave their homes.

• Adolescent services. Health educators and social workers work with adolescents to develop decisionmaking skills, support the adoption of preventive health practices, encourage family involvement, and prevent unplanned pregnancies and sexually transmitted infections (STI). • Integration of HIV prevention services. HIV prevention education and rapid testing services are fully integrated, identifying patients who are not aware of their status and linking them to care. In addition, we provide PrEP and PEP (post-exposure prophylaxis). • Community health education and outreach. The FPC/YMC conducts community-based outreach and activities to impact public awareness around family planning, STI and HIV prevention, and male health. • Co-located benefits enrollment and access to supportive services. The FPC/YMC conducts community-based outreach and activities to impact public awareness around family planning, STI and HIV prevention, and male health. • Recipient of NYC Council funding for services to immigrants. The YMC has received grant funding from the New York City Council for services to immigrants to help focus on decreasing health disparities among foreign-born New Yorkers. During January-June 2020, the Family Planning Practice saw 6,000 patients and provided benefits assistance to 6,000 patients.

Community Health Programs

CCHE: School-Based Health Center Program LEON SMART • Practice Administrator • lds9005@nyp.org MELANIE GOLD, DO, DABMA, DMQ, FAAP, FACOP • Medical Director • mag2295@columbia.edu Mission and Goals

Key Accomplishments

The School-Based Health Center (SBHC) Program is a network of primary care practice sites located within seven New York City Department of Education school campuses, housing 23 schools. SBHCs provide primary healthcare, immunizations, chronic illness management, sexual and reproductive health services, and care for acute illness and injury to all students on campus—facilitating access to care and preventing lost academic time. In addition, mental healthcare is fully integrated in the provision of care and provided on-site by psychologists, clinical social workers, and a psychiatrist. Dental services are available at select sites. Health educators provide individual counseling, conduct classroom education sessions—including evidence-based teen pregnancy prevention curricula— and train and lead peer educators who conduct educational sessions on a range of youth health promotion topics.

• Community Schools Mental Health Intervention. Via an evidence- based framework, a broad range of schoolbased mental health support services promote the emotional well-being and healthy functioning of all students on the George Washington Educational High School Campus. The three tiers encompass “universal” mental health services, which provide schoolwide resources to impart knowledge and promote a nurturing environment for all students; “selective” services, which support a subset of students at risk of developing mental health or substance use conditions; and “targeted” mental health services, which support students who have diagnosable mental health conditions.

Number of People Reached

6,000

otal number of patients T annually

800 Students receiving mental health services 2,000 Students receiving evidencebased classroom education

• NYPeers peer education and youth development. Annual cohorts of

youth leaders are identified to receive evidence-based training and conduct peer education on a host of health promotion topics. In addition, youth leaders spend a summer interning at the Hospital and gain professional skills and exposure to health career paths. • Integrative health in SBHCs. Mindfulness, self-hypnosis, acupuncture, acupressure, aromatherapy, and yoga are integrative health modalities offered at SBHCs. During January-June 2020, the SBHCs continued to provide medical and mental health services to students through telemedicine despite schools being closed because of COVID-19. During this period, 2,600 students received care.

Compass JANE CHANG, MD • Medical Director • jac9009@med.cornell.edu DAISY VELASQUEZ • Practice Administrator • dav9012@nyp.org Mission and Goals

The Compass Program is for transgender and gender-diverse children and adolescents. Compass began in the fall of 2018 and is located in the Helmsley Tower on the Weill Cornell Medicine campus. The multidisciplinary Compass team consists of an adolescent medicine physician, pediatric endocrinologist, psychiatric nurse practitioner, and adolescent social worker. In a safe, welcoming, and nonjudgmental space, Compass provides: • A comprehensive and individualized needs assessment • Mental health counseling • Family support • Gender-affirming hormone treatment In addition to patient care and family support, the team’s mission includes training pediatric providers and clinic staff to provide transgender-friendly care, advocating for transgender and gender-diverse patients within the NewYork-Presbyterian system and the outside community, and linking families with trans-affirming community resources. Future goals include offering both patient and parent support groups where participants can share their experiences and concerns. Compass is currently seeing patients with Medicaid insurance up through age 19.

The Compass Program is for transgender and gender-diverse children and adolescents. Compass, which began in the fall of 2018, is located in the Helmsley Tower on the Weill Cornell Medicine campus.

Community Health Programs

Center for Community Health Navigation PATRICIA PERETZ • Manager • pap9046@nyp.org ADRIANA MATIZ, MD • Medical Director • lam2048@columbia.edu Mission and Goals

The aim of the Center for Community Health Navigation (CCHN) at NewYorkPresbyterian is to promote the health and well-being of patients by providing culturally sensitive, peer-based support in emergency department, inpatient, outpatient, and community settings. The overall goal is to support healthcare self-management, connect patients with care, and decrease preventable system utilization. CCHN works to achieve its mission through five key activities: • Improving patients’ access to care at NewYork-Presbyterian and in the community. • Deepening connections between Hospital and community resources. • Developing and sustaining innovative patient-centered initiatives. • Advancing the community health worker role and workforce. • Enhancing the community health worker knowledge base and informing best practice. Key Accomplishments

Between 2008 and 2019, nearly 200,000 patients were supported by ED Patient Navigators across six EDs. Also, 77 percent of patients with a navigatorscheduled follow-up appointment attended the appointment, and 94 percent of patients without a primary

care provider had an appointment with a new provider upon discharge. Between 2006 and 2019, 2,400 children and their caregivers enrolled in the comprehensive Pediatric CHW Program. Among participating children with asthma, hospitalizations decreased by 76 percent and emergency department visits decreased by 68 percent, and 94 percent of caregivers reported being able to manage their child’s condition. Among children with special healthcare needs, 63 percent of caregivers reported decreased levels of stress, 100 percent reported that they knew how to access care for their child, and 97 percent reported feeling in control of their child’s condition. Between 2012 and 2019, 1,611 adults enrolled in the comprehensive Adult CHW Program. Among participants with diabetes, 62 percent experienced improved A1C levels and nearly 100 percent stated that they felt confident to reduce their risk upon graduation. Among adults discharged from the inpatient unit, 82 percent were not readmitted within 30 days of discharge. Finally, among adults with multiple comorbid conditions, 58 percent met their medication management goal and 60 percent met their patient navigation goal.

2019/2020 Highlights: With a generous $12.5 million gift from Pilar Crespi Robert and Stephen Robert, in 2019 CCHN launched new CHW and ED Patient Navigator programs at NewYork-Presbyterian Brooklyn Methodist Hospital and expanded these programs at NewYork-Presbyterian Lower Manhattan Hospital. In early 2020, CCHN launched the CHW and ED Patient Navigator programs in NewYorkPresbyterian Queens Hospital. In response to the COVID-19 pandemic, between March and August: • CHWs completed 7,600 wellness checks with patients and made 1,200 virtual social service referrals to support urgent needs, including food insecurity, housing, access to technology, and medication refills. • CHWs and Patient Navigators helped enroll nearly 3,600 patients onto NYP Connect and NYP On Demand platforms, allowing patients to virtually schedule and attend healthcare visits, access health records, and communicate with their providers.

Publications 1 Costich MA, Peretz PJ, Davis JA, Stockwell

MS, Matiz LA. Clinical Pediatrics. (2019) 58 (11-12), 1315-1320

2 Tiase VL, Peretz P, Biernacki et al. Computers,

Informatics, Nursing. 2017;9:447-451.

3 Garbers S, Peretz P, Greca E et al. J

Community Med Health Educ. 2016;6:440

4 Matiz LA, Robbins-Milne L, Krause MC, et al.

Clin Pediatr. 2016;55(2):165-70.

5 Matiz LA, Peretz PJ, Jacotin P et al. J Prim

Care Community Health. 2014;5(4):271-274.

6 Peretz P, Matiz A, Findley S et al. American

Journal of Public Health. 2012;102(8):14431446.

6 Peretz P, Matiz A, Findley S et al. American

Journal of Public Health. 2012;102(8):14431446.

7 Findley S, Rosenthal M, Bryant Stephens

T et al. Health Promotion Practice. 2012;12(1):52S-62S.

8 Mansfield C, Viswanathan M, Woodell C, Nourani V, Ohadike Y, Lesch J, Malveaux F, Bryant-Stephens T, Findley S, Lara M, Matiz A et al. Health Promotion Practice. (2011) Nov; 12(6 Suppl 1):34S-51S.

Presentations • An Emergency Department-Based Patient Navigator Program Supporting Vulnerable Patients to Navigate a Complex Health Care System. Annual American Public Health Association Meeting. Philadelphia, PA. 2019. • A Successful Hospital-Community Partnership Model Improving Outcomes for Rising-Risk Patients. Annual American Public Health Association Meeting. Philadelphia, PA. 2019.

• Understanding the Social Determinants of Health in Pediatric Patients Hospitalized for Asthma Through the Use of Community Health Workers. Pediatric Hospital Medicine Conference. Seattle, WA. 2019. • Impact of an Innovative Community Health Worker Program for Caregivers of Children With Special Healthcare Needs on Social Determinants of Health and Caregiver Distress. Pediatric Academic Societies Annual Meeting. Baltimore, MD. 2019. • Understanding the Social Determinants of Health in Pediatric Patients Hospitalized for Asthma Through the Use of Community Health Workers. Pediatric Academic Societies Annual Meeting. Baltimore, MD. 2019. • Evolution of a Community-Based Model to Support Caregivers of Children With Chronic Illness. American Public Health Association Annual Meeting. San Diego, CA. 2018. • Understanding the Social Determinants of Health for Latino Children With Special Healthcare Needs Through a Community Health Worker Program. Pediatric Academic Societies Meeting. Toronto, CA. 2018. • Expanding and Evolving a Proven Community Health Worker Partnership Model to Bridge Gaps in Care for Underserved Patients and Their Caregivers. American Public Health Association Annual Meeting. Atlanta, GA. 2017. • The Implementation of a CHW-Driven Tool to Improve Chronic Disease Self-Management in the PCMH. International Conference on Communication in Healthcare and Health Literacy Annual Research Conference. Baltimore, MD. 2017. • A Partnership Model to Bridge Gaps in Care for the Underserved Patients. Poster

presentation at the Reimagining Health in Cities: From Local to Global Urban Health Symposium. Philadelphia, PA. 2017. • Creation of a Center for Community Health Navigation: Preparation for the Post• DSRIP Era. New York Academy of Medicine Fourth Annual Population Health Summit: Working Across Sectors to Address Social Determinants of Health. New York, NY. 2016. • The Center for Community Health Navigation of NewYork Presbyterian Hospital. Komen Greater NYC Patient Navigation Conference. New York, NY. 2016. • A Nationally Recognized HospitalCommunity Model Bridging Gaps in Care for Patients in Lower Manhattan. Planetree International Conference on Patient-Centered Care. Chicago, IL. 2016. • Evolution of a Proven Community Health Worker Model Bridging Gaps in Care for Patients and Their Caregivers. American Public Health Association Annual Meeting and Exposition. Denver, CO. 2016. • A CHW-Led Initiative to Reduce the Burden of Chronic Illness in a Low-Income, Urban Community. American Public Health Association Annual Meeting and Exposition. Denver, CO. 2016. • Improving Care Transitions to Reduce Readmissions. Institute for Health Improvement Expedition Series. Virtual presentation. Denver, CO. 2016. • Integrating a Community Health Worker Into the Emergency Department. Institute of Education for the Care of Chronic Diseases Participatory Healthcare Practice and Education Conference. New York, NY. 2016.

Community Health Programs

Choosing Healthy & Active Lifestyles for Kids (CHALK) EMMA HULSE • Program Manager • emh9022@nyp.org DODI MEYER, MD • Medical Director • ddm11@cumc.columbia.edu Mission and Goals

NewYork-Presbyterian’s obesity prevention program, CHALK, is a collaboration with NewYorkPresbyterian/Columbia University Irving Medical Center and the Northern Manhattan community. CHALK’S aim is to lower the prevalence of childhood and adolescent obesity in Northern Manhattan by establishing an environment where healthy lifestyles are vital components of the lives of all families. CHALK’s programming is founded in 10 healthy habits adapted from Healthy Directions and its Healthy Children Healthy Futures program and further developed by community stakeholders to ensure that the habits are health literate and culturally sensitive and avoid stigmatization. CHALK’s areas of focus include community organizations and programs, early childhood centers, public elementary and high schools, faith-based organizations, and NewYork-Presbyterian’s outpatient pediatric practices. CHALK school partners are connected with a full-time staff member to help them assess and create wellness goals in collaboration with the organization’s leadership and wellness champions. Organizations choose from a “menu” of options, ranging from grant writing and partnership building to promoting healthy food and active design. This approach enables an organization to create, implement, and feel ownership over its wellness goals and projects.

This nonprescriptive approach and the fluidity of CHALK make the program model easily adaptable to a variety of settings. In 2020, CHALK continues to focus on food insecurity and capacity building with community-based organizations. Number of People Reached

CHALK partners include: 4

Early childhood centers

Elementary schools

High schools

Faith-based organizations

Community-based organizations

Farmers markets

ACN Primary Care Practices

Key Accomplishments

•C HALK elementary and high school partnerships expanded. A new community nutritionist joined the team, increasing access to nutrition appointments at school-based health centers and establishing two new school partnerships. Ten District 6 public schools received a combined $7,000 in grants to support wellness initiatives designed by school wellness councils and champions. Other school highlights include a new weight room at George Washington Educational Campus and seven professional development workshops held at elementary schools to increase staff confidence in implementing nutrition and physical activity policies. • CHALK Jr. launched a new early childhood center partnership in 2019 and continued to increase access to physical activity and healthy food across sites through active design projects, nutrition education, and a rooftop garden initiative. A food insecurity screener was developed for intake and an emergency food distribution program launched to support students’ families. • CHALK Youth Market Program is a partnership between CHALK and GrowNYC to offer paid summer internships to youth. Supervised by CHALK staff, interns worked at three farmers markets in 2019 and ran a farm stand outside an outpatient practice in Northern Manhattan. The program provides increased access to

fresh produce and health education for community members. In 2019, nine youth interns led over 100 market tours and raised $2,800 to support a local food pantry. In 2020, 20 youth interns joined the program and supported both the farm stand and CHALK’s emergency food distribution response to COVID-19. • The Fruit and Vegetable Prescription Program is a collaboration between the NewYork-Presbyterian Ambulatory Care Network’s Nutrition Department, Grow NYC, and CHALK, and is funded by NewYork-Presbyterian Community Relations. Registered dietitians “prescribe” fruits and vegetables for their patients. The prescription is redeemable for $10 in fruit and vegetable coupons at the Grow NYC tents of the 168th Street, 175th Street, and Isham greenmarkets. In 2019, a $20 prescription option was added for patients experiencing food insecurity. In total, 712 patients received one or more prescriptions in 2019, and $15,730 of fresh, local produce was purchased. • To increase access to emergency food resources, CHALK’s mobile market initiative expanded after a successful pilot in 2019. Launching in May, 50 families received groceries twice monthly from West Side Campaign Against Hunger’s client-choice-style mobile market. The pilot contributed to a 15 percent decrease in food insecurity among participants after two months. After the onset of the COVID-19 pandemic, the program grew rapidly to support families experiencing food insecurity across Northern

Manhattan and the Bronx. CHALK partnered with NewYork-Presbyterian healthcare teams, public schools, and local community-based organizations El Nido and Mexican Coalition to reach 1,255 unique households and distribute 159,630 pounds of healthy food between March 15 and July 31, 2020. As the pandemic and economic shutdown sent ripples across the city, NewYork-Presbyterian invested $5 million to increase access to emergency food resources in Lower Manhattan, Brooklyn, Queens, and Westchester. NewYork-Presbyterian patients and community members at six sites will receive once- or twice-monthly grocery boxes for 12 months alongside connection to social services and entitlement enrollment. • In September 2019, CHALK launched the Capacity Building Initiative to increase support for communityand faith-based organizations. The inaugural conference—Building a Stronger CBO—was attended by 80 community members representing 50 different organizations. Workshops focused on fundraising, data and evaluation, and working with public officials. After the conference, a workshop and webinar series launched. Plan A Consulting provided one-on-one support to three community-based organizations and crisis coaching to two organizations following the onset of the COVID-19 pandemic.

Community Health Programs

Community-Based Sexual Health MARIA V. ESPINAL • Practice Administrator • mrd9075@nyp.org x PETER GORDON, MD • Medical Director • pgg2@columbia.edu SUZANNE SCHLEGEL • Practice Administrator • sschlege@nyp.org x SAMUEL T. MERRICK, MD • Medical Director • stm2006@med.cornell.edu Number of People Reached

Mission and Goals

Sexual health programming for the community is a collaborative effort between community partners and the NewYork-Presbyterian HIV Centers of Excellence, the Comprehensive Health Program at NewYork-Presbyterian/ Columbia, and the Center for Special Studies at NewYork-Presbyterian/Weill Cornell. Medical, gynecological, psychosocial, and case management services are provided to people with HIV and those at risk for HIV, sexually transmitted infections (STIs), and hepatitis C. The patient-centered model of care features care coordinators, physicians, nurses, behavioral health clinicians, psychiatrists, and navigators. Project STAY (Services to Assist Youth), the young adults’ component, serves young people ages 13-24 onsite and in the community. The program aims to 1. increase access to and the capacity for prophylaxis (PrEP) services, 2. increase testing and screening, and 3. link and engage patients with care.

2,096

Patients assessed for PrEP; 75% started PrEP.

844

U nique clients engaged by Ready to End AIDS & Cure Hepatitis C (REACH) Collaborative, who received 2,000+ services.

1,200

C lients served by Youth Access Program (YAP) services.

1,400

P roject STAY sexual health education workshops.

1,200

C ommunity-based STI/HIV screenings through Project STAY.

Outreach, Screening, Linkage, and Prevention These efforts are achieved through Project STAY as well as a number of new community linkages. Project STAY Project STAY provides services for young people between the ages of 14 and 24 who are living with or at high risk for HIV; justice-involved youth; lesbian, gay, bisexual, transgender, queer, questioning, or pansexual; and men who have sex with men. 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 HIVpositive 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.

The New York City STD Prevention Training Center (PTC) is a CDC-funded program of Columbia University Mailman School of Public Health and a regional training center of the National Network of STD Clinical Prevention Training Centers. The PTC is dedicated to increasing the sexual health knowledge and skills of medical health professionals in the prevention, diagnosis, screening, and management of sexually transmitted diseases, with the goal of reducing the community burden of STIs and HIV — one of the key areas of focus for DSRIP. New Community Linkages (for STI/HIV testing) • The Point. A multi-service communitybased agency in the Hunts Point section of the Bronx. • Midtown Community Court. A program run by the Center for Court Innovation in Midtown Manhattan. • Alternative high schools. Goal is to expand the network to include Harlem Renaissance High School and several schools in the Bronx. • NYCDOHMH and LCOA (Latino Commission of AIDS). Enhanced referral of clients to NewYorkPresbyterian for PEP/PrEP.

Community Health Programs

Community-Based Sexual Health continued

Community Navigation, Community Health Work, and Care Management

These goals are accomplished through a collaboration with the Alliance for Positive Change, the REACH Collaborative, and Care Management Services.

REACH Collaborative. The team aims to achieve patient-centered sexual health goals and link clients to one of three NewYork-Presbyterian HIV Centers of Excellence or to Harlem United’s Federally Qualified Health Center (“The Nest”).

Community Navigation The CHP received City Council funding to support a collaboration with the Alliance for Positive Change to leverage a Health Information Exchange to reach out to, engage, and link patients lost to care by using technology to send alerts to primary care providers or the Alliance for Positive Change when patients present at healthcare or HASA facilities. In turn, a community navigator will meet patients in real time to facilitate care coordination. This project is scalable and is well aligned with the End the Epidemic mission. Community Health Work With the support of DSRIP funding, the REACH Collaborative includes the Alliance for Positive Change, WHCP, Argus Community Inc., and the Dominican Women’s Development Center. Subcontracts with CBO core partners support a team of eleven Community Health Workers (CHW) and peers and have extended outreach efforts through a mobile medical van. Together, CHWs and peers form a community-based health navigation team to coordinate care and linkage to the full range of support services offered across the

Care Management With partial support of a DSRIP-funded NewYork-Presbyterian Community Impact Grant, co-located Care Managers from the Alliance for Positive Change have been fully integrated into all three NewYork-Presbyterian HIV Centers of Excellence to provide comprehensive community-based Care Management Services.

The Comprehensive Health Program (CHP) and the Center for Special Studies (CSS) provide medical, gynecological, psychosocial, and case management services to people with HIV and those at risk for HIV, sexually transmitted infections, and hepatitis C.

Hepatitis C Program

Since 2015, the CHP has collaborated with the Washington Heights CORNER Project, a neighborhood syringe exchange program (SEP), in which CHP providers offer hepatitis C treatment onsite at the SEP. The work is funded by the NYSDOH AIDS Institute, and NewYork-Presbyterian supports a full time linkage specialist at the SEP. NewYork-Presbyterian’s 340b pharmacy assists with medication prior authorizations, and medication can be delivered directly to CHP, where adherence support can be provided.

Since 2015, 260 people with hepatitis C have been enrolled in this program and 105 have received treatment. Nearly all of those treated have been cured. In addition, approximately 15 patients have started buprenorphine therapy for opioid use disorder through this collaboration.

Community Health Programs

Community-Based Sexual Health continued

Publications 1 Carnevale C, Zucker J, Womack JA et al. Journal of Pediatric Health Care.

2018 Dec 26 (epub ahead of print).

7 Cohall AT. Am J Public Health. 2016;106(6):972-3. 8 Smith M, Mateo KF, Morita H, et al. Health Promot Pract.

2 Zucker J, Carnevale C, Rai AJ et al. Journal of Acquired Immune

2015;16(4):480-91.

Deficiency Syndromes, 2018;78(2), e11-e13.

3 Zucker J, Carnevale C, Slowikowski J et al. Predictors of Disengagement in

Care for Individuals Receiving PrEP. Accepted. Journal of Acquired Immune Deficiency Syndromes. 2019

4 Theodore DA, Zucker J, Carnevale C et al. Pre-exposure prophylaxis use

among predominantly African American and Hispanic women at risk for HIV acquisition in New York City. Submitted. AIDS and Behavior.

9 Nurses Improving HIV Prevention Through Partnership with the

Community —Emmet Phipps, FNP-BC, AAHIVS, PEP Center of Excellence, Chelsea Center for Special Studies, New York Presbyterian Hospital/Weill Cornell Medical Center, Brandon Elgün, MPH, PEP Center of Excellence, Chelsea Center for Special Studies, New York Presbyterian Hospital/Weill Cornell Medical Center.

5 Suglia SF, Shen S, Cohall A, et al. J Interpers Violence. 2016; Jul 31. 6 Armstrong BJ, Kalmuss D, Cushman LF, et al. Prog Community Health

Partnerships. 2016;10(2):225- 33.

Presentations • AIDS Institute Designated AIDS Center Conference. NewYork-Presbyterian’s • New York City Department of Education School Based Health Clinics Comprehensive Health Program: A Designated AIDS Program looking Training: PrEP for Young People – New York Presbyterian Project Stay. Long to past, present, and future models for opportunities to advance care. Island City, NY. June 2018. February 4, 2019. • Adolescent Sexual Health Symposium: Session D, Challenging STI Cases • PrEP Administration Workshop. Sponsored by Yale School of Nursing Panel. Sponsored by NYC STD Prevention Training Center. New York, NY: Students for Sexual and Reproductive Health (NSSRH). NewHaven, CT: March 2019. April 2018.

Selected Meeting Abstracts and Poster Presentations

• Attitudes in Assessing Patients for Pre-exposure Prophylaxis Among Pediatric and Internal Medicine Residents Training in New York City. HIV4RP. Madrid. October 2018.

• An Online Survey of Hepatitis C Testing Attitudes and Practice Habits Among Residents at an Urban Medical Center. ID Week. San Francisco, CA. October 2018.

• Pre-exposure Prophylaxis (PrEP) Uptake Among Predominantly Black and Latina Women at Risk for HIV Acquisition in New York. HIV4RP. Madrid. October 2018.

• Predictors of 6 Month Retention in a Minority Cohort of Men Who Have Sex With Men (MSM) on PrEP. ID Society of NY (IDSNY) Annual Harold Neu Symposium. New York, NY. May 2018.

Cultural Competency and Health Literacy Workgroup: A Collaboration between the Division and NewYork-Presbyterian Performing Provider System DODI MEYER, MD • Clinical Lead • ddm11@cumc.columbia.edu RACHEL A. NAIUKOW, MS, MPH • Program Coordinator • ran9031@nyp.org Mission and Goals

The overarching goal of the Cultural Competency and Health Literacy Workgroup is to provide guidance in cultural competence, language access, and health literacy to the Hospital and its community partners to enhance the quality of care and address healthcare inequities at the individual and population levels. The underlying principles for this work are to adopt a person-centered, cross-cultural approach that does not stereotype individuals; to use a population health approach that applies targeted interventions to populations in need; and to promote cultural competence, linguistic access, and health literacy standards as articulated in The National Culturally and Linguistically Appropriate Services (CLAS) Standards. The workgroup utilizes a multipronged approach to accomplish its goals. Work to date includes: • Multiple in-person and web-based trainings. Topics of these trainings are identified though a community-wide collaborator survey. • Creation of a framework to capture clinical data through an equity lens. • Dissemination of best practices in health literacy. • Participation in the NewYorkPresbyterian Diversity, Inclusion, and Belonging Committee.

The first annual Cultural Competency & Health Literacy in-person training event was held in fall 2017. Entitled “Instituting Agency Transformation for LGBTQ+ Inclusion,” it was well attended by Hospital and community agency representatives. There was also a bilingual community health talk for parents of young children. Webinars

and tip sheets have been co-developed with collaborators and distributed across the Hospital and community-based organizations with which the Division partners.

Community Health Programs

Health for Life ROBYN TURETSKY • Program Coordinator • rkt9001@nyp.org x JANE CHANG, MD • Medical Director, Health for Life East • jac9009@med.cornell.edu x JOHN RAUSCH, MD • Medical Director, Health for Life West • jr2163@cumc.columbia.edu Mission and Goals

Number of clinic visits in 2019 Presentations

The mission of Health 4 Life (H4L), a comprehensive weight management program, is to provide a safe and supportive environment for four- to 20-year-olds and their families who wish to improve their well-being through healthier diets and increased physical activity. Through individual clinic visits and group programming, H4L empowers participants to make healthier lifestyle choices for themselves and their families. The Health 4 Life program works with patients who have overweight or obesity as identified by their primary care physicians based on BMI percentile. Patients meet with doctors, dietitians, social workers, and a clinical exercise physiologist at each clinic visit. H4L families are encouraged to join group programming including physical activity for kids and nutrition education and support for parents.

250 Key Accomplishments

• H4L serves NewYork-Presbyterian Ambulatory Care Network patients at both the East and West Campuses. • Article publication in Obesity journal and presentation at the NYU Langone Comprehensive Program on Obesity’s symposium on COVID-19 and Obesity on using telehealth to serve children with obesity during COVID-19. • Transformation into a virtual program during COVID-19, serving patients through telehealth clinical visits and providing virtual exercise and nutrition education groups for kids and parents through Zoom.

• Foundations in Lifestyle Medicine course presentation to Weill Cornell Medicine students, 2017. • Presentation of Health for Life research results to the Weil Cornell Medicine Atkins Journal Club.

Health Home TIFFANY STURDIVANT-MORRISON, MPH • Lead • tis9034@nyp.org

Mission and Goals

The Division leads the NewYorkPresbyterian Health Home—a New York State Medicaid program that reimburses community-based organizations for the provision of highquality care management services to at-risk Medicaid beneficiaries. In this role, the Division forms the financial, analytical, clinical, and information technology backbone for a network of agencies that collaborate to enhance the Medicaid population’s health. As part of the Health Home, a dedicated care manager—at the Hospital or at a community-based organization—is assigned to Medicaid members who have complex medical and behavioral healthcare needs. The role of the care manager includes health promotion,

provision of individual and family support, and coordination of care and referrals to community and support resources. By providing these services, the NewYork-Presbyterian Health Home hopes to reduce avoidable emergency room visits and inpatient stays and improve its members’ health outcomes.

• Isabella Geriatric Center • NewYork-Presbyterian Ambulatory Care Management • Riverstone Senior Life Services • The Bridge • Upper Manhattan Mental Health Center

Number of People Reached

The Health Home network comprises care management agencies that provide services to 1,859 enrolled patients: • ACMH • Alliance for Positive Change

These agencies offer a broad portfolio of services, including behavioral health, housing, complex medical care, substance use treatment, and geriatric care. Services are available in Manhattan, Queens, Brooklyn, and the Bronx. Key Accomplishments

• Argus Community Inc. • CCN General Medicine • CREATE Inc.

Throughout the past year, the NewYorkPresbyterian Health Home has: • Generated $12 million of revenue for the Health Home Network since 2017. • Expanded its network by adding Center for Special Studies Care Management Team. • Collaborated with other Health Home networks to standardize best practices and conduct workshops for supervisor development. • Collaborated with several Hospital initiatives to facilitate care transitions for high-risk patients.

Community Health Programs

Healthy City Kids ROBYN TURETSKY • Program Coordinator • rkt9001@nyp.org ALLISON GORMAN, MD • Assistant Medical Director • agg9003@med.cornell.edu Mission and Goals

The mission of Healthy City Kids is to promote a healthy lifestyle and prevent obesity among families of preschool children. The program — which is delivered in partnership with the Lenox Hill Neighborhood House Head Start program — includes six weekly interactive sessions for parents of enrolled preschoolers and runs two to three times each year. A pediatrician and dietitian oversee the program, with each lesson taught by a pediatric resident.

Key Accomplishments

Families who have participated in Health City Kids report making numerous positive changes in their homes, such as buying healthier goods and encouraging their children to try new foods.

Lang Youth Medical Program ISABELLE ELTON • Program Manager • ise9007@nyp.org MARA MINGUEZ, MD • Medical Director • mm2060@cumc.columbia.edu Number of People Reached

Mission and Goals

The Lang Youth Medical Program (Lang Youth) is a six-year health science enrichment and medical pipeline program for underserved youth who represent the diversity of the Washington Heights and Inwood (WHI) communities. Lang Youth’s mission is to inspire and motivate middle school and high school students to achieve their college and career aspirations through hands-on learning and mentorship at a world-class academic medical center. Lang Scholars meet on Saturdays during the academic year and summers during July for six years from seventh through 12th grades. Lang Youth fosters an environment for academic and personal success through: • Health career exploration. Hospital tours, career panels, clinical rotations, and summer internships. • Health science education. Handson curriculum interweaving human anatomy, physiology, pathology, public health, and personal wellness.

230

umber of students and their N families Lang Youth has served over the past 15 years.

130 Students who have graduated from Lang Youth, graduated from high school, and matriculated into a four-year college/university since 2009. 85 Number of students currently enrolled in Lang Youth Key Accomplishments

Lang Youth aims to increase high school and college graduation rates, with the goal of improving health outcomes in the future. The program also helps to reduce the deficit of minority healthcare workers in the United States. • Lang Youth inducted 15 new Lang Scholars to the program, representing 11 of our partner middle schools in WHI. • The Program held its 12th annual graduation ceremony, and because

of COVID, it was the hospital’s first live virtual event. We celebrated 13 graduates. This cohort of Lang Scholars had an 86 percent retention rate over six years, and all are attending fouryear universities—including Boston University, Syracuse University, SUNY Binghamton, CUNY Hunter College, Brandeis, NYU, Lehman, Buffalo State, Howard, and Columbia University. • NewYork-Presbyterian welcomed its fifth Lang alumna as a full-time employee of the Hospital: Annabell Marcelino (Lang Class of 2013), who serves as Program Coordinator for the Uptown Hub. • For the first time, Lang Youth offered three summer internship placements to alumni. Sites included the Ambulatory Care Network Child Advocacy Center, Morgan Stanley Children Hospital’s Child Life Department, and Milstein Hospital’s operating rooms. • Recently, Lang Youth launched its first online new scholar application. It hopes to increase outreach to eligible sixth-grade students attending public/ charter middle schools in WHI.

• Mentorship. Guidance from graduate students, medical trainees, and healthcare professionals from various Hospital departments. • College support. College campus tours, SAT preparation, college application assistance, and academic and career development for Lang Youth alumni.

Community Health Programs

Manhattan Cancer Services Program KAREN SCHMITT, MA, RN • Director • schmitt@nyp.org

Mission and Goals

The Manhattan Cancer Services Program (MCSP) aims to reduce disparities and improve cancer outcomes among underserved adults in New York State. The program serves individuals regardless of health insurance status in difficult-to-reach Manhattan communities, as well as those enrolled in primary care through the ambulatory care network who are outside of guidance-concordant cancer screening. MCSP uses evidenced-based initiatives to overcome barriers to care and increase adherence to cancer screening and diagnostic services. This is accomplished by grant-funded staff who: •D eliver community-based education, outreach, and access to care. •P rovide and coordinate no-cost screening and diagnostic services funded by the NYSDOH and the CDC. •R efer patients to treatment. •E nroll patients diagnosed with cancer into the Medicaid Cancer Treatment Program. •O ffer case management services through the continuum of care. •P rovide cancer support services in English and Spanish. •O ffer patient navigation services to identify and overcome social determinants of health barriers, education and counseling on the importance of cancer screening, and enrollment into screening and care coordination throughout diagnostics into treatment. 40

Number of People Reached

In the last 5-year funding cycle: 6,946 Received cancer education and were recruited through community outreach 994 Recruited through communitybased-outreach screening 3,807 Uninsured individuals completed all needed screening 547 Received case management care coordination services 32

Diagnosed with cancer

2,030 ACN patients received patient navigation services and completed screening Key Accomplishments

There are multiple points of entry to MCSP through nine service providers in Manhattan: New York Presbyterian/ Columbia University Irving Medical Center, Charles B. Wang Community Health Center, Bellevue Hospital, CallenLorde Community Health Center, Ryan/ Chelsea-Clinton Community Health Center, Ralph Lauren Center, Project Renewal, Multi-Diagnostic Services Inc., and the Mount Sinai Mobile Mammography Program. Currently, MCSP has an active community partner list of more than 400 community-based organizations, faith-based organizations, schools, local elected officials, and service agencies

with which we collaborate to offer our services and to whom we refer our patients for social services. MCSP works with the Herbert Irving Comprehensive Cancer Center to develop, disseminate, analyze, and monitor community cancer needs and inform and direct community programs in education, service, and access to care. MCSP is also spearheading an expanded Community Cancer Screening Services initiative to address cancer health disparities in our catchment area. This initiative uses the MCSP Patient Navigation model to identify, assess, enroll, and navigate community members into breast, cervical/ HPV, colorectal, smoking cessation, lung, prostate, hepatitis and liver, melanoma, and primary care screening and diagnostic services targeting populations at highest risk for incidence and mortality from these cancers. MCSP is also working with Breast Imaging leadership to create collaborations with community providers, schools, and faith-based organizations to facilitate access to breast cancer screening, regardless of health insurance status. MCSP supported the COVID response by enrolling patients into telehealth/ telephonic visits for primary care and providing referrals to service organizations for food insecurity, housing instability, and legal and financial matters exacerbated by the pandemic.

Publications 1 Hillyer GC, Beauchemin M, Hershman

DL, Kelsen MA, Brogan FL, Sandoval R, Schmitt KM, Reyes A, Terry MB, Lassman AB, Schwartz GK. Comparison of attitudes and beliefs about cancer clinical trial enrollment between physicians, research staff, and cancer patients. 2019. J Clin Oncol; 37(27_supp): 170-170.

2 San Miguel S, Reyes A, Hillyer GC, Schmitt

KM, Whitaker D, Lopez J, Vadaparampil ST, Easter, Bailey L, Springfield. Cancer genetics services and health disparities among racial/ethnic minority populations: Implementing culturally-tailored educational outreach through the community health educators (CHEs) of the national Outreach Network. AACR American Association for Cancer Research Annual Meeting 2020.

3 Hillyer GC, Schmitt KM, Reyes A, et al.

Community education to enhance the more equitable use of precision medicine in Northern Manhattan. J Genet Couns. 2020:29:247-248.

Abstracts and Presentations 1R eyes, A, Schmitt, KM, Sandoval et al. Ensuring

diversity in cancer research participation by using culturally appropriate modalities. Abstract. 43rd Annual Meeting of American Society of Preventive Oncology, March 10-12, 2019.

2 S chmitt KM. Patient Navigation in Large

Health Systems. New York State Department of Health Cancer Services Program Meeting, Albany, NY, January 2019.

3H illyer GC, Shea S, Schmitt KM et al.

Assessment of lung cancer screening needs in Northern Manhattan: A pilot study. Abstract presented at the American Society of Preventive Oncology, March 11-14, 2017.

Grants • New York State Department of Health Integrated Cancer Services Program — Manhattan Cancer Services Program/Cancer Navigation Program (2018-2023). • Davida T. Deutsch Breast Cancer Support Program (2016-present). • Grace B. Lamb Trust (2017-present) — Treatment Support for Uninsured. • Komen Greater NYC (2018-2019). • P30 Herbert Irving Comprehensive Cancer Center (2013-2019) — Community and Ambulatory Research Shared Resource. • NCI National Outreach Network Community Health Education Program — Cancer Genetics Education Program (2015-2019).

4 Hillyer GC, Schmitt KM, Nazareth M,

Reyes A, Agarwal A, Burke K, Terry MB. Preliminary results from the Herbert Irving Comprehensive Cancer Center Community Cancer Needs Assessment. NCI Grantee Conference at American Society of Preventive Oncology, March 2020.

Community Health Programs

NewYork-Presbyterian Performing Provider System Impact Grants BRIAN YOUNGBLOOD • Project Leader • bjy9001@nyp.org

Mission and Goals

The Division of Community and Population Health provides an opportunity for community-based organizations interested in expanding collaboration to develop novel interventions to support vulnerable populations. Using Delivery System Reform Incentive Payment funding, the Division released a request for proposals to the network of community collaborators to solicit programming ideas. Key Accomplishments

In 2019, the NewYork-Presbyterian Performing Provider System completed an eight-week competitive RFP process to award $1.3M in Community Impact Grants to seven community agencies: • ACMH. Short-Term Crisis Respite & Transitional Step-Down Housing, staffed 24/7 by peers with lived experience with mental illness, provides shortterm housing for individuals residing in the community and experiencing a psychiatric crisis. It also provides a step-down for patients discharged from the hospital who may not be ready for a full transition back into the community. The objective of Respite/Step-Down is to improve participants’ engagement in behavioral health services, primary care, and other services and supports in the community, as well as develop wellness and recovery action plans in order to reduce avoidable inpatient and emergency department utilization. 42

• ArchCare. The grant will expand access to pediatric home healthcare with the goal of reducing hospital recidivism and emergent care visits by managing the family at home in collaboration with the patient’s medical team. The grant will support the recruitment, hiring, and onboarding of four additional pediatric home care nurses who will provide care for an additional 400 infants and children. • Association to Benefit Children. ABC’s Fast Break Plus Program is a mobile (in-community/in-home) therapeutic program designed to meet patients literally where they are and provide therapeutic services in the most natural contexts. This agile team consisting of a licensed therapist, a family advocate, and a youth advocate will be overseen by ABC’s board-certified child psychiatrist and a senior-level supervisor. Services from this team will include psychotherapy, family support and advocacy (such as family safety

planning and culturally aligned discussions of strengths/needs), and youth support and advocacy (such as advocacy at a school meeting, support to attend an appointment, or problem-solving about peer relationships). ABC will use a variety of evidence-based tools to provide services, such as trauma-focused CBT, Triple P parenting skills training, and motivational interviewing. Since ABC hopes to connect with patients (under 18 years) who engage the NewYork-Presbyterian Morgan Stanley Children’s Hospital emergency room for mental health crises (or those who are medically hospitalized but have untreated mental health disorders), ABC will embed a licensed therapist each day of the week in the Hospital’s emergency room (8 a.m.-7 p.m.) to connect immediately with the patient and the caregiver.

• Community League of the Heights. (CLOTH). Community League of the Height’s Healthy Challenge Program will work with residents of Washington Heights and Inwood to develop a yearlong exercise and wellness plan to address health and wellness issues. The program will include multiple sessions of weekly group exercise classes, a nutrition and lifestyle change curriculum, and monitored check-ins with wellness and medical experts. The Challenge will incorporate a connection with NewYork-Presbyterian community health workers to ensure that participants have medical oversight and an appropriate plan for critical health issues such as diabetes, hypertension, asthma, and obesity. CLOTH’s hope is that this program will help vulnerable individuals and their families adopt a healthy lifestyle that will reduce reliance on emergency medical systems, create a comfortable connection to primary and preventive care specialists, and connect residents to other critical services that support healthy lifestyles—safe and affordable housing, food pantry, adult literacy and education, and bilingual education. • Lenox Hill Neighborhood House. Lenox Hill Neighborhood House will implement a Patient Navigator Program at its Women’s Mental Health Shelter. The aim of this program is to increase post-emergency department discharge follow-up and treatment adherence, as well as reduce avoidable ED use, by directly assisting clients with the post-ED visit

treatment plans and referrals provided by the NewYork-Presbyterian/Weill Cornell Medical Center Emergency Departments. In addition, the Patient Navigator will work with all shelter clients regardless of ED utilization to assess unmet healthcare needs and ensure familiarity with local ambulatory services, create new or reestablish existing connections to necessary healthcare providers and/or Health Homes, and motivate all clients to establish a regular pharmacy and receive an annual wellness check. • Northern Manhattan Perinatal Partnership. NMPP, in collaboration with the NewYork-Presbyterian Allen Hospital Obstetric Department and NewYork-Presbyterian Ambulatory Care Network Charles B. Rangel Community Health Center, will provide services that will address maternal mortality disparities among pregnant and postpartum women. Services will include a health navigator, community health workers, and postpartum doulas to assist women and their families to effectively access continuous and coordinated healthcare and other services, including home visiting to ensure prenatal and postpartum visits are attended. Community health workers will address key barriers that impact maternal health outcomes, including providing health education and support, promoting social support networks, connecting to community resources, and increasing health literacy.

he postpartum doula will support T the mental and physical wellbeing of Mom, which will include assisting with breastfeeding support, addressing issues of postpartum depression, and ensuring completion of the postpartum visit. • Service Program for Older People. (SPOP). Service Program for Older People Inc. will partner with NewYorkPresbyterian to provide behavioral healthcare services for Medicaid beneficiaries age 55 and older who are affiliated with or referred by the NewYork-Presbyterian system. SPOP will provide assessments, psychotherapy and psychiatric services, home visits (for disabled clients), medication management, and connections to other supports as needed. The goals of the project are to improve overall health and quality of life and reduce unnecessary hospital emergency room usage.

Community Health Programs

Outreach Program MONICA HIDALGO • Manager • moh9017@nyp.org x DEBORAH ACEVEDO, RN • Nurse Coordinator • acevedd@nyp.org KAYLEEN GARCIA • Program Coordinator • kag9132@nyp.org Mission and Goals

Key Accomplishments

The Outreach Program aims to promote health and prevent disease through education and screening with a focus on early detection and interventions. The goal is to connect at-risk people in the community with a reliable source of primary medical care. The program evaluates and prioritizes the needs of underserved residents in the communities surrounding NewYork-Presbyterian Hospital campuses. Its goal is to reduce health disparities in our communities.

During the Bodegueros Health Initiatives at Jetro Cash and Carry in the South Bronx, out of 200 individuals screened, 40 percent presented with hypertension. Participants received counseling and education about the importance of primary care services.

Our events include free screenings, services and counseling, health insurance information, and vetted educational presentations that are culturally reflective and relevant to members of the community. Examples include the BiAnnual Domestic Workers Events, monthly Bodegueros (Grocery Shop) Health Events, and a Men’s Health Event in partnership with livery taxi driver leaders. Number of People Reached

2,000 P eople screened at targeted health events

In addition, we organized our annual community flu clinics which served approximately 300 people. In partnership with NewYork-Presbyterian Nursing, we were able to increase our educational offerings at The Bowery Mission, The Good Counsel Home for Pregnant Women in the Bronx, and other community-based organizations. We also expanded our work with the homeless population in Washington Heights and Harlem while continuing our efforts with The Bowery Mission Salvation Army, NYC Rescue Alliance, and The Church of the Epiphany. The Outreach team also led NewYorkPresbyterian’s involvement in World Pride. Held in New York City in 2019, World Pride is the largest international celebration of the LGBTQ+ community. The event reached millions of people from across the globe. The year 2020 gave us the unique opportunity to virtualize much of this work. We remained engaged with our collaborators by offering educational workshops via Zoom, and providing

financial support to mitigate the challenges presented by COVID-19. We were also able to provide thousands of surgical face masks, shields, and notouch thermometers to community and faith-based organizations. As the City began to plan for reopening, a NewYork-Presbyterian nurse practitioner offered guidance to many of our community organizations via Zoom, as well as in-person walkthroughs of community facilities. The plans were developed to meet the needs of the organizations while observing recommendations from the Centers for Disease Control and Prevention.

Community Health Programs

Reach Out and Read Program EMELIN MARTINEZ • Program Manager • emm9016@nyp.org DODI MEYER, MD • Medical Director • ddm11@cumc.columbia.edu Mission and Goals

Reach Out and Read is a national hospital-based program that trains and supports medical providers who give books to children and advice to parents about the importance of reading aloud at each well-child visit until the patient reaches six years of age. The ROR program of NewYork-Presbyterian/ Columbia University Irving Medical Center is one of the largest in New York State. Foster grandparents read to children in waiting rooms at all sites, and volunteers model reading techniques to children in the waiting room. Books are distributed. At each wellchild visit, a patient age six months to five years receives a new culturally and developmentally appropriate book. nticipatory guidance is given. A Pediatricians underscore reading aloud to a child as an essential activity that helps children develop strong literacy skills. Volunteers model and motivate. Provide a positive reading experience while demonstrating read-aloud techniques in the presence of patients’ caregivers. Underscore reading as an engaging activity for children that makes the waiting room ambience more pleasant.

Number of People Reached

• Nearly 10,000 patients throughout 11,330 well-child visits among five Pediatric Ambulatory Care Network sites • A total of 12,932 books were disseminated by medical providers to patients during well-child visits Three foster grandparents and two college volunteers read aloud to pediatric patients and model family literacy strategies to pediatric caregivers in the waiting room. In 2019, the ROR foster grandmothers and volunteers served 580 hours.

Underscore reading as an engaging activity for children that makes the waiting room ambience more pleasant.

Substance Use Disorder Peer Program CARMEN JUAN • Program Lead • caj9033@nyp.org

Number of People Reached

Mission and Goals

In March 2019, NewYork-Presbyterian Hospital launched a substance use treatment improvement effort to provide direct care services to patients with opioid and other drug-related conditions. In collaboration with Services for the Underserved (S:US), a community-based organization that provides a range of healthcare, care coordination, and social services to individuals in New York City, the Division of Community and Population Health supported the development of the Substance Use Disorder (SUD) Peer Program. The program embedded peers in the emergency department and inpatient units at NewYork-Presbyterian/ Columbia University Irving Medical Center, NewYork-Presbyterian Allen Hospital, and NewYork-Presbyterian Lower Manhattan Hospital.

The program plan is to offer these services to the Weill Cornell Medical Center campus and other NewYorkPresbyterian network entities. The SUD Peers have worked on-site to identify, engage, link, and provide continuity of care and treatment for patients. Peers have also provided education and briefings to cross-discipline hospital staff on their services in order to spread more awareness of this care model and assist with access to resources.

514

F rom March 2019 to year’s end, 514 patients were referred to the program. This program reflects the efforts of the hospital to create a pathway of care for these patients.

These efforts are part of NewYorkPresbyterian’s goal to provide progressive and state-of-the-art treatment for this cohort of patients. Patients are kept on a roster for followup and outreach and can be seen not only on-site but also in the community.

These efforts are part of NewYorkPresbyterian’s goal to provide progressive and state-of-the-art treatment for this cohort of patients.

Community Health Programs

Summer Youth Experience Program SHARON KIM • Co-Lead• shk9051@nyp.org ISABELLE ELTON • Co-Leas• ise9007@nyp.org Mission and Goals

In response to the dearth of summer opportunities for youth this year, NewYorkPresbyterian’s Division of Community and Population Health, in close partnership with NewYork-Presbyterian’s Department of Human Resources, developed a three-pronged approach to address this deficit: (1) virtual programming through the Uptown Hub, (2) in-person placements for children of NewYorkPresbyterian employees, and (3) financial support for efforts led by communitybased organizations. Together, these three offerings helped the youth in our immediate and surrounding communities to engage in meaningful experiences while supporting the local economy by providing stipends to all participants.

Virtual Experience—Learn, Try, Apply Summer 2020 Led by NewYork-Presbyterian’s Uptown Hub in collaboration with the Lang Youth Medical Program and NYPeers, LTA utilized a virtual curriculum developed in partnership with community-based organizations to provide workshops and internships for youth ages 12-24. The curriculum focused on public health, sustainability, art, music, film, science, technology, and social justice. Participants of LTA also attended presentations by guest speakers from diverse professional backgrounds including Brian Yang (Hollywood actor), John Starks (retired Knicks basketball player), and Dr. Julia Iyasere, vice president of NewYorkPresbyterian’s Center for Health Justice.

Community-Based Organization Collaborators: • Dominican Women’s Development Center • Northern Manhattan Improvement Corp. • People’s Theatre Project • Police Athletic League •T he YM&YWHA of Washington Heights & Inwood • Azeotrope (Technology Consultants) • Building Beats • Center for Sustainable Development, Columbia • NYU Tisch School of the Arts—Film Students • STEM Kids • Uptown Stories • Washington Heights & Inwood Pathways • Young Life Applicants: 2,995 49% Black/African American 54%

Latinx

Some applicants selected both options for ethnic background. 96% Students Enrolled: 301 37% from Washington Heights ZIP codes 63% Other zipcodes

In-Person Placements For Children Of NewYork-Presbyterian Employees Led by the Division of Community and Population Health and NewYorkPresbyterian Human Resources, the Paid Summer Youth Experience Program provided placements for the children of NewYork-Presbyterian employees. Participants were placed at most campuses including, NewYorkPresbyterian Brooklyn Methodist, NewYork-Presbyterian Hudson Valley, and NewYork-Presbyterian Queens. The goal of this arm of the program was to expose young adults to the breadth and depth of hospital professions while providing mentorship and hands-on career training In preparation for the commencement of their on site assignments, the group participated in an online orientation that featured a recorded welcome message from Shaun Smith, senior vice president and, chief people officer. It also included COVID/ PPE training and presentations on various topics including college preparedness, career exploration, and the NewYork-Presbyterian Respect Credo. As a continuation of their professional development, we also launched our Leadership Engagement Achievement Development (LEAD) series. Through LEAD, the interns were able to participate in the following presentations: Technology at NewYorkPresbyterian, Resume writing & social media workshop, Anti-bias/ unconscious racism presentation with Bart Bailey, and various presentations hosted by Talent Development.

Community-Based Organization Collaborators: • Community League of the Heights • Chinese-American Planning Council • Stanley Isaacs • Queens Chamber of Commerce

Other Financial Support For Community-Based Organization-Led Summer Experience Community League of the Heights: Serving 210 youths Westchester Youth Bureau: Serving 35 youths

• Prospect Park Alliance

Chinese-American Planning Council: Serving 15 youths

Applicants: 1,104

Queens Chamber of Commerce: Serving 15 youths

American Indian or Alaska Native

Stanley Isaacs: Serving 55 youths

171

Asian

487

Black/African American

Prospect Park Alliance: Serving 15 youths

320

Latinx

4 Native Hawaiian or Other Pacific Islander 6

Two or More Races

103

White

(Blank)

Total Served: 345 Total Youth Served Through Three Interventions: 800

Parent Job Family: 1,104 206

Allied Health Professionals

249

Clerical

Finance

Information Tech

Maintenance

Nonclinical/Professional

244

Nursing/Nursing Management

293

Service & Accommodations

Offers: 195 Enrolled: 153 49

Community Health Programs

The Family PEACE (Preventing Early Adverse Childhood Experiences) Trauma Treatment Center CYNTHIA ARREOLA • Program Manager • cya9006@nyp.org WANDA VARGAS, PHD • Senior Psychologist • wav9004@nyp.org Mission and Goals

The goal of Family PEACE (Preventing Early Adverse Childhood Experiences) Trauma Treatment Center (FPTTC) is to help very young children and their families heal after experiencing family violence, abuse, and other forms of trauma. The Center provides holistic treatment to end intergenerational cycles of violence, offering services to young children (ages birth to five years), their primary caregivers, and siblings (ages six-12 years) who have also been impacted by the traumatic event. Services include: • Dyadic, individual, and group treatment for young children and their caregivers • Creative arts and integrative therapies • Case management and crime victim compensation assistance • On-site legal services • Psychiatry services The FPTTC provides trauma-informed and culturally attuned programming that reflects the needs of the community. Staff are bilingual and bicultural, and services are offered in both English and Spanish. The clinical staff consists of mental health professionals who are specialists in early childhood mental health and development, trauma, and parent-child attachment.

In an effort to identify trauma early and enhance access to treatment for young children and families, the Center implemented the Healthy Steps Model at NewYork-Presbyterian’s pediatric primary care setting. Caregivers and young children were screened for exposure to trauma, provided with information about trauma and health, and streamlined into a plan of treatment to meet their needs. The Center also partnered with local community-based organizations, including early childhood centers, to offer training and consultation on building a trauma-informed system, implement trauma screening, and provide on-site treatment services.

In an effort to identify trauma early and enhance access to treatment for young children and families, the Center implemented the Healthy Steps Model at NewYorkPresbyterian’s pediatric primary care setting.

Number of People Reached

3,355

Visits with 303 unique patients.

560 Individuals (267 adults and 293 children) screened for trauma using the Adverse Childhood Experiences (ACEs) tool. 65 Medical residents/interns trained on trauma/ACEs and how to screen for domestic violence in the primary care setting. 372 Direct service providers from NewYork-Presbyterian and partner agencies trained on trauma-informed care). 55 Individuals (adults and children) received legal services.

Caregivers and young children were screened for exposure to trauma, provided with information about trauma and health, and streamlined into a plan of treatment to meet their needs. Key Accomplishments

Supported by a grant from the New York State Office of Victim Services, the Family PEACE Trauma Treatment Center expanded its treatment interventions to include a creative arts and integrative therapies component. The Center offers music therapy, spirituality groups, and workshops focused on healing the mind-body connection. The expansion and diversification of treatment interventions allows for a holistic approach to healing that is grounded in the cultural values and norms of the community. The FPTTC’s grant from the National Child Traumatic Stress Network/ SAMHSA for “Increasing Community Access to Early Childhood EvidenceBased Trauma Services” has allowed for the integration of behavioral health services into primary care and community-based organizations; training and education on traumainformed systems of care; early identification of trauma using the ACEs tool; improving access to treatment; and developing a trauma-informed culturally attuned model of care.

The FPTTC was selected to participate in the National Council on Behavioral Health’s one-year program on TraumaInformed, Resilience-Oriented Learning Community. The program served to enhance FPTTC’s model of traumainformed service delivery. The FPTTC remains active in the community’s grassroots and advocacy efforts against domestic and gender-based violence and is a member of the Washington Heights/ Inwood Coalition Against Interpersonal and Domestic Violence and the Upper Manhattan Collaborative. The Center also co-chairs the Intimate Partner Violence Collaborative Group for the National Child Traumatic Stress Network and its affiliates.

Community Health Programs

Turn 2 Us (T2U) EVELYN MONTAÑEZ, PHD, LCSW • Program Manager • montaev@nyp.org EVELYN BERGER-JENKINS • Medical Director • eb283@cumc.columbia.edu Mission and Goals

Turn 2 Us (T2U) is a school-based mental health promotion and prevention program at NewYorkPresbyterian Hospital in partnership with Columbia University Irving Medical Center, public elementary schools in Washington Heights/Inwood Center, and Derek Jeter, co-owner of the Miami Marlins and CEO and Founder of the Turn 2 Foundation. T2U is dedicated to promoting mental health and academic success in atrisk children and raising awareness of the importance of mental health even in the absence of mental health conditions. Our goals are to: • Mitigate and/or prevent mental health conditions in at-risk youth. • Foster healthy lifestyle practices that promote the well-being of the school community. • Enhance the mental health literacy of school personnel and parents so they are best equipped to ensure students’ social and academic success. • Decrease the stigma associated with mental health. Number of People Reached

Since its inception, T2U has reached over 12,500 students, caregivers, and school personnel.

Key Accomplishments

1. Primary/Universal Services at PS128M, PS115M, PS8M, PS4M. Delivered a series of mental health promotion initiatives for thirdthrough fifth-graders, teachers, and all parents. In addition, we trained school-designated “key champions” for the purpose of replicating and sustaining initiatives at their sites. Mental Health Literacy (MHL) for School Personnel at PS128. • 30 staff members completed an MHL baseline survey as part of the training aimed to enhance their literacy and ability to support students’ MH needs. • Five MH professional development workshops were delivered: MH disorders/stigma; prevalence and impact of trauma; trauma-informed practices in classrooms; classroom management strategies; self-care (34 staff attended). • Smaller focus groups were held (per grade) to reinforce strategies learned in the training and address ongoing challenges in the classrooms (25 staff attended). Mental Health Literacy (MHL) for Parents/Caregivers (reached 126). • A series of bilingual workshops were held to support/enhance knowledge of common school-age disorders, as well as resources and self-care and stress management strategies, and decrease mental health stigma.

I n-Class Mindfulness Exercises (ICME) (380 students & 15 teachers @ PS128M). A two-part curriculum promoting positive thinking, stress management, and self-efficacy was delivered to all thirdthrough fifthgraders in 14 classrooms. • Part 1: Presentation on how to recognize, manage, and reduce stress. • Part 2: Six-week demonstration on in-class mindfulness exercises to increase teachers’ efficacy in interweaving ICME into daily curriculum. Healthy Lifestyle Campaign (1,283 students and 44 staff). Assemblies and in-class workshops were provided to thirdthrough fifthgraders in four sites to promote healthy lifestyles and test-taking/ coping skills: • PS128: 380 students, 14 teachers (assembly & in-class workshops) • PS8: 460 students, 11 teachers (inclass workshops) • PS115: 218 students, nine teachers (assembly) • PS4: 225 students, 10 teachers (assembly)

2. S econdary/Targeted Services at PS115, PS8, PS4, PS28, PS48, PS173, PS189. Sports Youth Development Basketball and Baseball Leagues for fourth- and fifth-graders were developed for students identified by school personnel and/or parents as at risk for mental health challenges. Nonreferred students are also enrolled to prevent stigmatization. The program served 552 students across eight schools and provided: •S ocial-emotional learning opportunities and mentorship to support academic and social progress. • Tailored consultations with parent, teacher, coach, and student. • Tracking and monitoring of classroom compliance, social performance, attendance, and mental health symptoms. T2U continues to sponsor one of the largest elementary school-based SYDLs in Northern Manhattan.

3. COVID-19 Response at PS128, PS8, PS4, PS28, PS48, PS115, PS173, PS189. Parent and School Personnel Support & Resources • Created and distributed handouts via schools’ e-learning platforms: “Helping Children Cope With Changes Resulting From COVID-19” (3,500+). • On June 17, Dr. Berger-Jenkins and Dr. Montanez provided a parent workshop on strategies to support the well-being of their family during the pandemic (78). • Conducted outreach to families in our program identified as high risk by school personnel (i.e., active ACS cases) (eight).

Student Support & Resources (4,000+ students) • Developed and disseminated via schools’ e-learning platforms a twopart narrated PowerPoint in dual language to help students cope with stress: “Superheroes’ Tips for the Brain, Body, and Mood.” • Developed and implemented a sixweek virtual Mentorship Program for over 300 students in our Sports Youth Development League, with support of coaches from all seven school sites and Turn 2 Foundation. It aimed to help students cope with the changes resulting from COVID-19 (coping, problem-solving, goal setting, skills).

• Provided ongoing communication with school administrators and educators to provide for and assess the mental health needs of the school community (19).

Community Health Programs

Turn 2 Us (T2U) continued

4. C ommunity Outreach. Community District 12 Youth and Education Committee: Dr. Montanez was invited as guest speaker. Topic: “Supporting Youths’ Social-Emotional Development Through Mental Health Literacy” (Nov. 19, 2019).

5. Our program outcomes include: Study participant outcomes** • 40 percent decrease of depression/ anxiety symptoms and 21 percent decrease of disruptive symptoms in high-risk students. • 20 percent decrease of mental health stigma in school staff. • 17 percent increase in school staff confidence in addressing students’ mental health needs.

Publications 1 Montanez E, Berger-Jenkins E, Rodriguez

J et al. “Turn 2 Us: Outcomes of an Urban Elementary School-Based Mental Health Promotion and Prevention Program Serving Ethnic Minority Youths.” National Association of Social Workers. 2015;1-8.

2 Raval G, Montañez E, Meyer D, Berger-

• 15 percent decrease in absences.

Jenkins E. School-Based Mental Health Promotion and Prevention Program “Turn 2 Us”.

• 15 percent improved standardized test scores in English/language arts and seven percent in math.

Reduces Mental Health Risk Behaviors in Urban, Minority Youth. Journal of School Health, 2019, 89:8.

Schools participating in study** • 60 percent decrease in multiple unscheduled guidance visits over two years. • 60 percent decrease in disciplinary actions over two years. ** Percentage reflects students and school personnel

3 Montañez E, Finkel M, Haley C, Berger-

Jenkins E. (Under review) Turn 2 Us: Building Mental Health Literacy of School Personnel to Reduce Barriers for Success in Latino Youth.

4 Montañez E, Zhang P, Berger-Jenkins E.

(Work in Progress) Urban Elementary School Personnel’s Perspectives on Addressing Mental Health Issues With Students.

5 Montanez, E. (Work in Progress) Turn

2 Us Manual: Develop, Sustain, and Evaluate Mental Health Promotion Program.

Grants

• Derek Jeter’s Turn 2 Foundation (2009-present). • Healthy Tomorrow HRSA Grant (2019-present). • Leaves of Grass (2019-present).

Waiting Room As a Literacy & Learning Environment (WALLE) EMELIN MARTINEZ • Program Manager • emm9016@nyp.org DODI MEYER, MD • Medical Director • ddm11@cumc.columbia.edu Mission and Goals

The Waiting Room As a Literacy & Learning Environment (WALLE) is an initiative of the NewYork-Presbyterian Ambulatory Care Network. WALLE 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, motivation interviewing skills, and the transtheoretical model.stheoretical Model. The goals of the program are to: • Provide approaches designed to improve quality of care, patient satisfaction, and health education.

• Support clinical staff by providing supplemental counseling and resources for patients. • Maximize provider-patient interactions and optimize time spent in the waiting room by engaging patients. WALLE staff members aim to achieve these goals by: • Linking patients with free/low-cost community resources. • Giving patients relevant health education and improving their health literacy. • Telling medical providers about patients’ needs as identified by their caregivers. • Supporting medical providers with health education. • Assisting patients with the completion of medical forms, as needed. • Recruiting interns to serve ACN patients (124 interns were recruited in 2019, an increase of nearly 50% from the previous year).

Key Accomplishments

In 2019, WALLE continued to work in collaboration with the Addressing the Needs of the Community through Holistic Organizational Relationships (ANCHOR) program and assisted with the administration of 15,841 SDOH screenings across various ACN sites to help identify patients who may have screened positive for food insecurity, housing stability/quality, transportation, and utilities. These screenings helped identify 4,955 low-risk and 1,511 high-risk patients, according to the criteria set in place by the Center for Medicare & Medicaid Innovation Grant. Six WALLE Navigators joined the team during the latter half of 2019 and worked in collaboration with Community Resource Coordinators by helping to initiate navigation services to patients who were classified as high-risk. One hundred and twenty-four WALLE interns from over 30 higher learning institutions were recruited and trained to serve in the outpatient clinical settings of the Ambulatory Care Network, where services have been expanded to the department of internal medicine and OB-GYN patients. WALLE interns collectively served nearly 20,000 hours in 2019.

Community Health Programs

Uptown Hub SHARON G. KIM, LMSW• Program Manager • shk9051@nyp.org x ERICA M. CHIN, PHD • Director of Psychology and Co-Principal Investigator • erc9027@nyp.org x ALWYN T. COHALL, MD • Co-Principal Investigator • atc1@cumc.columbia.edu Number of People Reached

Mission and Goals

Since 2017, NewYork-Presbyterian’s 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. In partnership with several communitybased organizations, the Uptown Hub provides a free and safe space for young people to connect, create, and grow as well as access holistic and culturally affirming services and resources. Objectives • 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. • To reduce idle time, risky behaviors, and justice system involvement through an individualized support system that fosters positive relationships with peers and mentors. • To improve mental and physical health by supporting psychological development and enhancing resilience and acquisition of coping skills. • To increase the collective impact of youth-serving agencies and to expand community awareness of available services through enhanced collaboration.

589

otal Members Enrolled Since T 2018

450 Workshops (Employment, Education, Health/Wellness, Youth Development) 322 Monthly Average of Drop-In Visits Community Collaborators •C olumbia University Irving Medical Center (CUIMC) •D ominican Women’s Development Center (DWDC) •N orthern Manhattan Improvement Corp. (NMIC) • People’s Theatre Project (PTP) • Police Athletic League (PAL) • The YM & YWHA of Washington Heights and Inwood (The Y)

The Uptown Hub provides a free and safe space for young people to connect, create, and grow as well as access holistic and culturally affirming services and resources.

Key Accomplishments

In 2019, the Uptown Hub had a number of key accomplishments that reflected its mission to improve the well-being of youth and young adults in the community, which included: Supportive Guidance. The Supportive Guidance program was established with the addition of four Hub Advocates. Upon joining the Hub, every member is assigned a Hub Advocate who provides individualized support, referrals to resources, and general mentorship and coaching. Behavioral Health Services. The Uptown Hub Behavioral Health team provided preventive and comprehensive psychological services. Wellness and affirming psychosocial groups were made available to all Hub members. Comprehensive services included diagnostic evaluations and individual and group interventions, as well as neuropsychological testing. The Uptown Hub team is multidisciplinary; all staff members partnered and collaborated in team case conference reviews contributing to treatment planning and prevention-focused screening of mental health needs in our community. Behavioral health screening and engagement services were available to members on-site in the drop-in youth development space.

Medical Services. Hub Members had access to medical services, particularly reproductive and sexual health services, primarily through NewYorkPresbyterian’s Project STAY, Young Men’s Clinic, and Family Planning Clinic. Employment Readiness & Educational Support. The Uptown Hub hosted employment-readiness-related activities year-round, such as resume and interview skills workshops. Additionally, select Hub Members participated in job training programs or other paid experiences through Hub community partners NMIC (Train & Earn, Intern & Earn, YouthBuild), DWDC (Uptown’s Voices), and PTP (Luna Ensemble). In summer 2019, the Uptown Hub hosted a cohort of about 40 SYEP Younger Youth from The Y, providing them shadow opportunities at NewYork-Presbyterian Allen Hospital. All interns participating in CHALK’s Summer Youth Market internship program and CCHE’s NYPeers program were enrolled as Hub Members. Beyond employment services, a volunteer group composed of CUIMC medical students offered tutoring on a weekly basis.

and a variety of Hub Clubs (e.g., Hub Acting Up with PTP, Healthy Living with NMIC). Hub Members also participated in volleyball and basketball at PAL. Youth Advisory Council & Teens Unite for Health. The Uptown Hub Youth Advisory Council welcomed a new group of young leaders to provide feedback about Hub programming and work on service projects. The Council, along with several other youth volunteers, planned NewYorkPresbyterian’s 2019 Teens Unite for Health event held at Highbridge Recreation Center, which was attended by approximately 300 youth across New York City. Uptown Hub Youth Center. The Uptown Hub’s new physical site at the Department of Health and Mental Hygiene building on 168th Street and Broadway completed its design phase with anticipated construction in 2020 and site opening in January 2021.

Creative Youth Development. As a drop-in space, Hub Members accessed amenities such as free Wi-Fi and laptops, snacks and refreshments, games and entertainment, and a study space on a daily basis (Monday through Friday). The Hub also offered structured workshops, such as Manhood 2.0, Sisters Table, Uptown Pride with DWDC (LGBTQIA+ group), All About Me with NewYork-Presbyterian’s Pastoral Care,

Community Health Programs

Women Infant and Children Program (WIC) NALINI CHARLES • Program Manager • nac9026@nyp.org

Mission and Goals

The NewYork-Presbyterian Ambulatory Care Network’s Women, Infants, and Children (WIC) program is a federally and state-funded nutrition education and supplemental foods program. WIC clients can receive nutritional counseling, healthy lifestyle support, and breastfeeding promotion and support, as well as individualized food packages for eligible participants.

The launch of the new electronic benefits transfer system at NewYorkPresbyterian’s WIC program in 2019 allowed us to issue benefits to our participants remotely. This was especially important during the crisis of the COVID-19 pandemic in New York, where the NewYork-Presbyterian WIC staff was able to serve an average of 9,327 participants a month remotely via telephone, allowing us to reach a great deal of our participants.

Number of People Reached

WIC serves approximately 10,500 participants each month.

Key Accomplishments

Our Breastfeeding Help & Referral Center provides one-on-one breastfeeding support plus aids such as breast pumps, breast shells, and nipple shields to WIC participants. WIC works with mothers to increase the rates of breastfeeding initiation and duration. We continue to strive for higher breastfeeding rates through education and support provided by our nutrition and peer counseling staff.

Our Breastfeeding Help & Referral Center provides one-on-one breastfeeding support plus aids such as breast pumps, breast shells, and nipple shields to WIC participants.

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 beyond.

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.

Division of Community & Population Health 2020

Articles inside

Women, Infants, and Children Program (WIC

Uptown Hub

Waiting Room As a Literacy & Learning Environment (WALLE

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

Substance Use Disorder Peer Program

Reach Out and Read Program

Lang Youth Medical Program

Outreach Program

Healthy City Kids

Health for Life

Cultural Competency and Health Literacy Workgroup: A Collaboration between the Division and NewYork-Presbyterian Performing Provider System

Community-Based Sexual Health

Compass

Choosing Healthy & Active Lifestyles for Kids™ (CHALK

CCHE: School-Based Health Center Program

ANCHOR (Addressing the Needs of the Community Through Holistic, Organizational Relationships

Division of Community and Population Health: Our Mission

Center for Community Health and Education

Behavioral Health Clinical Services (Outpatient

Executive Summary

Building Bridges, Knowledge and Health Coalition

Community Health Needs Assessment and Community Health Service Plan

CCHE: Family Planning Program and Young Men’s Clinic