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

DODI MEYER, MD • Clinical Lead • ddm11@cumc.columbia.edu EVA LERNER, MSW, MPA • Program Manager • evl9023@nyp.org

Mission and Goals Number of People Reached

In 2017, the Division of Community and Population Health 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.

21,306

1,036

833

Number of patients screened.

Number of high-risk patients accepting navigation services and referred to communitybased organizations.

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.