A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community

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A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

By J. Emilio Carrillo, Nida Shabbir Shekhani, Emme Levin Deland, Elaine M. Fleck, Jaclyn Mucaria,
Robert Guimento, Steven Kaplan, William A. Polf, Victor A. Carrillo, Herbert Pardes, and Steven J. Corwin        doi: 10.1377/hlthaff.2011.0635
                                                                                                                 HEALTH AFFAIRS 30,
                                                                                                                 NO. 10 (2011): –

A Regional Health Collaborative                                                                                  ©2011 Project HOPE—
                                                                                                                 The People-to-People Health
                                                                                                                 Foundation, Inc.

Formed By NewYork-Presbyterian
Aims To Improve The Health Of A
Largely Hispanic Community
                                                                                                                 J. Emilio Carrillo (ecarrill@
 ABSTRACT   Communities of poor, low-income immigrants with limited                                              nyp.org) is vice president of
                                                                                                                 community health at
 English proficiency and disproportionate health burdens pose unique                                             NewYork-Presbyterian
 challenges to health providers and policy makers. NewYork-Presbyterian                                          Hospital and an associate
                                                                                                                 professor at Weill Cornell
 Hospital developed the Regional Health Collaborative, a population-based                                        Medical College, in New York
 health care model to improve the health of the residents of Washington                                          City.

 Heights–Inwood. This area is a predominantly Hispanic community in                                              Nida Shabbir Shekhani is a
 New York City with high rates of asthma, diabetes, heart disease, and                                           manager in the Office of
                                                                                                                 Strategy at NewYork-
 depression. NewYork-Presbyterian created an integrated network of                                               Presbyterian Hospital.
 patient-centered medical homes to form a “medical village” linked to
                                                                                                                 Emme Levin Deland is senior
 other providers and community-based resources. The initiative set out to                                        vice president for strategy at
 document the priority health needs of the community, target high-                                               NewYork-Presbyterian
 prevalence conditions, improve cultural competence among providers,
 and introduce integrated information systems across care sites. The first                                       Elaine M. Fleck is an
                                                                                                                 associate clinical professor of
 six months of the program demonstrated a significant 9.2 percent decline                                        medicine in the Ambulatory
 in emergency department visits for ambulatory care–sensitive conditions                                         Care Network of NewYork-
                                                                                                                 Presbyterian/Columbia, in New
 and a 5.8 percent decrease in hospitalizations that was not statistically                                       York City.
 significant. This initiative offers a model for other urban academic
                                                                                                                 Jaclyn Mucaria is senior vice
 medical centers to better serve populations facing social and cultural                                          president for ambulatory care
 barriers to care.                                                                                               and patient-centered services
                                                                                                                 at NewYork-Presbyterian

                                                                                                                 Robert Guimento is vice
                                                                                                                 president for ambulatory care

              population-based model of health        meet the documented health needs of the local              at NewYork-Presbyterian
             and health care encompasses the          community by incorporating cultural compe-                 Hospital.
             ability to assess the health needs       tency, using information systems such as elec-
                                                                                                                 Steven Kaplan is the chief
             of a specific population; implement      tronic health records and disease registries, and          medical director and quality
             and evaluate interventions to im-        coordinating care across the continuum. The col-           and patient safety officer for
prove that population’s health; and provide care      laborative encompasses the entire neighbor-                ambulatory care at NewYork-
for individual patients in the context of the pop-    hood of Washington Heights–Inwood, in upper                Presbyterian Hospital.

ulation’s culture, health status, and health          Manhattan, to help improve the health of the
                                                                                                                 William A. Polf is senior vice
needs.1 NewYork-Presbyterian Hospital, in asso-       community by reducing health disparities at                president for external
ciation with the Columbia University Medical          both the individual and population levels. The             relations for NewYork-
Center, has developed a population-based, col-        goal is to uniformly enhance and align the health          Presbyterian Hospital.
laborative model of regional health planning and      care systems throughout the neighborhood to
                                                                                                                 Victor A. Carrillo is the
care coordination designed to measurably im-          improve overall access and quality for the entire          director of community health
prove health and reduce disparities.                  population.                                                development at NewYork-
  This model, called the NewYork-Presbyterian           In 2008—recognizing that the residents in its            Presbyterian Hospital.
Regional Health Collaborative, aligns services to     community were experiencing gaps in care and

                                                                                  O c to b e r 2 0 1 1   30:10   H e a lt h A f fai r s           1
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

                                unmet needs in the context of escalating health        The Community According to information
Herbert Pardes is executive     costs—NewYork-Presbyterian initiated a major         from the New York State Department of Health,
vice chairman of the board of
trustees of NewYork-
                                review of the health care delivery model. The goal   NewYork-Presbyterian serves more than 60 per-
Presbyterian Hospital.          was to create a system of care modeled on the        cent of the 270,000 residents of Washington
                                concept of population-based health. The hospital     Heights–Inwood, a community geographically
Steven J. Corwin is chief       wanted the system to meet identified needs of the    bounded by the Hudson and Harlem Rivers.
executive officer of NewYork-
Presbyterian Hospital.
                                community; improve access to care; and coordi-       Most of the residents are poor, Spanish-speaking
                                nate care for each patient, wherever he or she       immigrants who face socioeconomic and health
                                received care.                                       disparities compared to residents of other parts
                                  The hospital reviewed the services it provided     of Manhattan and New York City (Exhibit 2).3–5
                                and conducted a formal health needs assessment       Consequently, taking the residents’ culture, lan-
                                of the community, using existing health and cen-     guage, and health literacy into account plays an
                                sus data and feedback from community groups,         important role in efforts to meet health needs
                                staff physicians and nurses, and groups of physi-    and reduce health disparities in this community.
                                cians unaffiliated with NewYork-Presbyterian.
                                The hospital and Columbia University Medical
                                Center developed a rational, coordinated system      Study Data And Methods
                                to deliver care to the community and agreed to       Gathering Information As noted above, in
                                monitor progress through measurable out-             2008 NewYork-Presbyterian completed a com-
                                comes. The transformed system launched in Oc-        prehensive qualitative and quantitative commu-
                                tober 2010.                                          nity health needs assessment, which updated a
                                                                                     study conducted in 2006.5,6 The new study ana-
                                                                                     lyzed structural, cognitive, and health care ac-
                                Background                                           cess barriers related to health knowledge among
                                The Hospital NewYork-Presbyterian Hospital is        community residents, as well as cross-cultural
                                a 2,278-bed academic medical center that pro-        communication needs among community resi-
                                vides patient care, teaching, research, and com-     dents and providers.7 Data were obtained from
                                munity service to a large and diverse population     the Census Bureau, the New York City Depart-
                                in New York City. It is the teaching hospital for    ment of Health and Mental Health, and existing
                                two major universities, Columbia University Col-     studies and surveys. Focus groups and interviews
                                lege of Physicians and Surgeons and Weill Cor-       with key informants—including members of
                                nell Medical College. The hospital’s attending       existing community- and faith-based groups—
                                physicians are employed directly by the two          provided input on the residents’ perceptions of
                                medical schools. NewYork-Presbyterian Hospi-         their health needs.
                                tal’s facilities are spread across five campuses        These analyses identified prevalent chronic
                                in the New York City area.                           diseases and needed preventive services. The re-
                                   Although much of the discussion around na-        sult was clinical and population health protocols
                                tional health care reform has focused on features    that are consistent with nationally recognized
                                of integrated delivery systems—as exemplified        evidence-based standards and guidelines.
                                by Mayo Clinic, Geisinger Health System, and            The Collaborative The NewYork-Presby-
                                Kaiser Permanente—the great majority of hospi-       terian Regional Health Collaborative is an on-
                                tals in the United States are not organized as       going effort that began in 2008 and has gone
                                integrated systems. Most traditional academic        through four developmental phases. Phase 1
                                medical centers, like NewYork-Presbyterian,          lasted one year and involved more than 140
                                serve the complex needs of people living in their    multidisciplinary participants at NewYork-Pres-
                                service areas by providing care through a hospi-     byterian Hospital, Columbia University, and two
                                tal and several off-site clinics. Many patients      organizations of independent community physi-
                                use hospitals’ emergency departments for rou-        cians. Together these organizations developed
                                tine care.                                           recommendations based on health needs, access
                                   In 2010 NewYork-Presbyterian provided care        barriers, and structural challenges and identi-
                                in 1.8 million outpatient visits and discharged      fied key areas of improvement that the collabo-
                                more than 117,000 inpatients. More than 40 per-      rative would focus on. The targeted areas were
                                cent of the outpatient visits came through the       cultural competency, information technology,
                                Ambulatory Care Network, which includes the          access to care, and the patient-centered medical
                                hospital and seven stand-alone community             home.
                                health center practices in the Washington               In phase 2, which lasted six months, the
                                Heights–Inwood area. The clinics treat a pre-        groups developed program recommendations,
                                dominantly Hispanic population with public in-       defined resource and cost challenges, and iden-
                                surance (Exhibit 1).2                                tified initial strategies for implementation. Rec-

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A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
ognizing that access to care was a recurring           Exhibit 1
theme, the groups recommended developing
                                                      Demographic Characteristics Of Ambulatory Care Network Patients At NewYork-
a patient-centered medical home model at New          Presbyterian Hospital, 2008
   Implementation began during 2010, in phase           Characteristic                                                     Percent
3, as process and outcome measures and emer-            Race/ethnicity
gency department and inpatient hospital utiliza-        Hispanic                                                           68
tion metrics were established to monitor and            Black                                                              13
track progress. Phase 4 began in 2011, with             Non-Hispanic white                                                  8
                                                        Other                                                              11
the goals of providing complete care co-
ordination across the continuum of services
and supporting the conversion of community
                                                        Medicaid                                                           60
physician practices into patient-centered medi-         Medicare                                                           18
cal homes. This phase is expected to last well          Self-pay                                                           11
into 2012.                                              Private insurance                                                   6
                                                        Other                                                               5

Strategies And Programs
                                                      SOURCE Note 3 in text.
Four multiyear strategies were formulated to ad-
dress the findings of the 2008 study, as follows:
establishing patient-centered medical homes;
exchanging health information; implementing           ogy, nursing, quality, and strategy depart-
a targeted care intervention; and creating a          ments—met for eight months to lead the imple-
“medical village”—or interlinked medical homes        mentation of the patient-centered medical home
connected to other health care providers, such as     model across the network of clinics. The first
hospitals, as well as additional community re-        step was to design and integrate information
sources, such as home care providers. The strat-      technology dashboards with up-to-date patient
egies are discussed below.                            information summaries and a registry—an ag-
   Establishing Patient-Centered Medical              gregate clinical data repository that allows for
Homes                                                 trend analysis and data reporting—into clini-
   ▸▸ TRANSFORMING CLINICS INTO MEDICAL               cians’ work flows.
HOMES : Based on recommendations from                   Next, patient flow within each clinic and be-
phases 1 and 2 of the collaborative, NewYork-         tween centers of care was redesigned to accom-
Presbyterian adopted the National Committee           modate a patient-centered approach that incor-
for Quality Assurance’s patient-centered medical      porated disease and population management
home model8 for the Ambulatory Care Network
practices and school-based health centers. The
                                                       Exhibit 2
yearlong implementation phase—phase 3—in-
cluded a site-specific analysis of the gaps in care   Demographic Characteristics Of Residents Of Washington Heights–Inwood And New York
at each primary care clinic in the Ambulatory         City, 2000
Care Network. Key internal and external stake-
                                                                                                   Washington Heights–
holders—such as hospital leaders, students from         Characteristic                             Inwood                            New York City
Columbia’s Mailman School of Public Health,             Race/ethnicity
and members of the community—conducted                  Hispanic                                   76%                               27%
the analyses, which also assessed each clinic’s         White non-Hispanic                         14                                35
readiness to meet National Committee for Qual-          Black/African American non-Hispanic         8                                24
ity Assurance standards for becoming a patient-         Asian/Pacific Islander                      2                                10
centered medical home.                                  Literacy and education
   Diabetes mellitus, congestive heart failure,         Born outside United States                 50                                36
asthma, and depression were identified as the           Speak Spanish at home                      62                                48
four conditions to be targeted during the first         Less than 9th grade educationa             23                                10
stage of implementing the patient-centered              Income
medical home model. These four were chosen              Median household income                    $28,865                           $38,293
based on the 2008 health needs assessment               Unemployment rate                          14.5%                             9.6%
                                                        Percent with household income below
and the documented prevalence of the condi-
                                                          federal poverty level                    30                                21
tions at each clinic.
   A multidisciplinary group of approximately
fifteen hospital leaders—including physicians         SOURCES Notes 6 and 7 in text. NOTES Not all percentages sum to 100 because of rounding. New York
and staff members from information technol-           City includes Washington Heights–Inwood. aFor those over age twenty-five.

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A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

                      strategies. Multidisciplinary care teams were es-     framework and seven domains of cultural com-
                      tablished, and all team members were trained in       petency guided the programmatic efforts and led
                      cultural competency and the use of the new elec-      to employing bilingual and bicultural commu-
                      tronic dashboards and registry.                       nity health workers and “navigators” of the
                         All patients with diabetes, asthma, congestive     health system to help provide culturally compe-
                      heart failure, or depression were automatically       tent care.9
                      entered into a disease registry and were followed        NewYork-Presbyterian implemented a four-
                      longitudinally in accordance with evidence-           hour training program that used a skills-based
                      based clinical guidelines. Depression screening       and patient-based approach, aimed at building a
                      was highlighted and integrated into the disease       workforce that could address the linguistic, cul-
                      registry. Patient education was expanded and          tural, and health literacy needs of patients.10 As
                      targeted according to the clinical severity of each   of May 2011 approximately 1,100 employees in
                      patient’s condition.                                  the emergency department and Ambulatory Care
                         ▸▸ THE MEDICAL HOME DESIGNATION : The Na-          Network had received this training.
                      tional Committee for Quality Assurance has des-          The hospital also set up an Office of Care Man-
                      ignated NewYork-Presbyterian’s seven commu-           agement—initially focused on managing the four
                      nity-based ambulatory care centers as level 3         targeted conditions—where culturally compe-
                      patient-centered medical homes. This designa-         tent nursing staff guided patients across inpa-
                      tion is the highest level of patient-centered medi-   tient and outpatient settings and oversaw their
                      cal homes and is based on specific criteria that      transitions of care. This office contacts patients
                      reflect the organization’s evidence-based and co-     who are admitted to NewYork-Presbyterian and
                      ordinated primary care patient-centered medical       makes follow-up appointments for them at their
                      home services.8 Another eight Washington              patient-centered medical homes. Care managers
                      Heights–Inwood school-based health centers            also follow the disease registry in order to iden-
                      are preparing to apply for this designation. New      tify adverse patterns of utilization and clinical
                      York-Presbyterian is one of the very few US aca-      indicators—such as repeat visits to the emer-
                      demic medical centers to have large networks of       gency department, underuse of hemoglobin
                      level 3 patient-centered medical homes—an             A1c diabetes tests, or abnormally high values
                      achievement emblematic of the high-quality care       of hemoglobin A1c—and intervene as appro-
                      provided to the Washington Heights–Inwood             priate.
                      community.                                               Exchanging Health Information Informa-
                         The complete set of patient-centered medical       tion technology solutions have included the de-
                      home services became fully operational at all         velopment of a personal health record for each
                      seven clinics October 4, 2010. This is considered     patient, patient-specific disease dashboards, and
                      the “patient-centered medical home initiation         a population-based disease registry. The per-
                      date”—the time when patients had access to            sonal health record allows patients to view their
                      the enhanced and coordinated services of the          medical records and access medical information
                      patient-centered medical home.                        on any electronic device that connects to the
                         ▸▸ RELATED GOALS : Improving access was            Internet. The disease dashboards automatically
                      identified as a major need, so several initiatives    pull data such as critical laboratory and clinical
                      targeted this. The existing decentralized call cen-   values, inpatient admissions, emergency depart-
                      ters where patients scheduled appointments,           ment visits, and past clinic visits from NewYork-
                      learned test results, and received follow-up in-      Presbyterian’s information technology systems,
                      formation were transformed to a centralized           including the electronic health record, clinical
                      contact center for information and appointment        labs, and patient registration systems.
                      scheduling. Over a five-month period, the num-           These dashboards give patient care teams a
                      ber of repeat calls from patients fell because ser-   longitudinal snapshot of an individual patient
                      vice was improved and more problems were re-          over time. They also alert clinicians who are car-
                      solved in initial calls. NewYork-Presbyterian         ing for a patient when examinations, tests, or
                      worked with community health workers to iden-         screenings are pending or overdue, thus ensur-
                      tify and communicate with people who might be         ing timely and appropriate evidence-based thera-
                      eligible for, but not enrolled in, the Children’s     peutic and preventive interventions.
                      Health Insurance Program or Medicaid, or who             The same electronic health record is used
                      might not be receiving services for which they        throughout the Ambulatory Care Network and
                      were eligible.                                        the hospital, allowing for a seamless flow of in-
                         Another goal of the initiative was to improve      formation across transitions of care. There are
                      cultural competency, specifically across the Am-      electronic population-based disease dashboards
                      bulatory Care Network and in the emergency            for all ambulatory care patients with a primary or
                      department. The 2009 National Quality Forum           secondary diagnosis of diabetes mellitus,

4    Health Affairs    Octo ber 2 011     3 0:10
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
asthma, congestive heart failure, or a combina-        sitions, matching patients to a patient-centered
tion of these three targeted conditions who vis-       medical home, and other care management strat-
ited one of the seven ambulatory care clinics on       egies, many of which are being implemented
or after January 1, 2010. Depression screening         through the NewYork-Presbyterian Regional
has been incorporated into all three disease           Health Collaborative.12
dashboards and the disease registry to facilitate         Consequently, the targeted care intervention
treatment and care management. A comprehen-            focused on the critical hospital-to-home transi-
sive list of data fields for depression is currently   tion period to minimize preventable readmis-
under development.                                     sions. The three major elements of the targeted
   Between October 2010 and July 2011, 7,731           care intervention model were comprehensive
patients with diabetes, 2,030 with congestive          discharge planning, beginning when a patient
heart failure, and 6,550 with asthma were              is admitted or arrives at the emergency depart-
added to the registry. The registry captures vital     ment; management of transitions of care, includ-
patient-centered medical home and care man-            ing a home visit, by a rapid-access team consist-
agement data, such as visits to school-based           ing of a nurse practitioner or nurse and
health centers or the emergency department,            community health worker; and linking the pa-
inpatient admissions, blood pressure, and levels       tient with a patient-centered medical home.
of hemoglobin A1c and low-density lipoproteins            The intervention incorporated elements that
(LDL), or “bad” cholesterol.                           had proved to be effective at NewYork-Presby-
   The same protocols, standards, and evaluation       terian, such as the use of community health
methodologies are applied to each patient. The         workers to help reinforce patient education
registry is built and managed by an information        and providing ongoing support and monitoring
technology team at NewYork-Presbyterian, but it        after discharge. In addition, the design of the
is designed to allow disease management and            intervention adopted key elements of Mary
care teams to study specific populations in the        Naylor and colleagues’ transitional care model
database independently. This allows providers to       and Eric Coleman and colleagues’ care transi-
identify specific high-risk patients or groups of      tions intervention.13,14
patients and proactively direct them to care at the       Creating A Medical Village A medical village,
patient-centered medical homes, which avoids           according to the NewYork-Presbyterian Region-
unnecessary emergency department visits and            al Health Collaborative, is a geographically
hospitalizations.                                      defined community with a number of patient-
   Implementing The Targeted Care Inter-               centered medical homes linked to other provid-
vention To better meet the needs of chronically        ers and community-based resources. The con-
ill adult patients with multiple conditions, the       cept has been described previously in the health
initiative also included a targeted care interven-     care literature.15
tion that identified the causes of frequent read-         The first goal of NewYork-Presbyterian’s medi-
missions and excess use of the emergency de-           cal village in Washington Heights–Inwood was
partment. NewYork-Presbyterian conducted a             to collaborate with the New York City and State
detailed analysis of historical patient utilization    health departments to help local physician prac-
data to assess readmission risk, using a model         tices adopt electronic health record systems,
developed by John Billings and colleagues to           transform themselves into patient-centered
identify patients at high risk of readmission to       medical homes, and establish health informa-
a hospital in the next twelve months.11                tion exchanges. NewYork-Presbyterian has de-
   A “root cause analysis” that included chart and     veloped a Spanish-language personal health rec-
patient reviews and physician focus groups for a       ord16 and is preparing to disseminate it across the
sample of 273 high-use patients identified the         medical village in 2012. Multiple community ser-
following as major contributors to costs: multi-       vice efforts, described in the online Appendix,17
ple medications; care involving multiple provid-       add to the impact of the medical village.
ers, which can be highly fragmented and un-
coordinated; lack of a primary care physician;
and inadequate management of care transitions.         Study Results
Further chart analysis indicated that high rates       Preliminary utilization results for patients in the
of depression, social problems such as homeless-       existing disease registry—for diabetes mellitus,
ness, and cultural and language barriers were          congestive heart failure, and asthma—seen dur-
common among frequent users of hospital                ing October 2010 indicate decreased emergency
services.                                              department visits for ambulatory care–sensitive
   Substantial evidence suggests that there are        conditions—diagnoses best dealt with in an out-
opportunities to improve quality and reduce            patient setting—and hospitalizations during the
costs by improving the management of care tran-        six months after the patient-centered medical

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A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

          Exhibit 3                                                                                                        patients to a cohort based on their first date of
                                                                                                                           service in one of the seven patient-centered
Emergency Department Use By Patients With Diabetes, Asthma, Or Congestive Heart
Failure, NewYork-Presbyterian Hospital, 2010–11
                                                                                                                           medical homes on or after October 4, 2010.
                                                                                                                           The baseline data in Exhibits 3 and 4 include
                                                                                                                           the number of emergency department visits
                                                                                                                           and hospitalizations at NewYork-Presbyterian
                                                                                           Emergency department visits     within the six months preceding the first pa-
                                                                                           Patients visiting the
                                                                                                                           tient-centered medical home visit—that is, the
Number of visits or patients

                                                                                           emergency department
                                                                                                                           start of the cohort time period. Similarly, emer-
                                                                                                                           gency department visits and hospitalizations
                                                                                                                           after implementation are those during the six
                                                                                                                           months after the start of the cohort time period.
                                                                                                                              The October 2010 cohort (N ¼ 5; 963 pa-
                                                                                                                           tients) is the first group for which we have six
                                                                                                                           months of utilization data since the implemen-
                                                                                                                           tation of the patient-centered medical home
                                                                                                                           model (Exhibit 5). Baseline utilization for this
                                                                                                                           group was a mean of 0.59 visits per patient in the
                                                                                                                           cohort to the emergency department (standard
                                                                                                                           deviation: 1.176; 95% confidence interval: 1.15,
                                                                                                                           1.21). After implementation of the patient-
SOURCE NewYork-Presbyterian Hospital disease registry. NOTES “Baseline” is utilization in the six                          centered medical home model, emergency de-
months before October 2010, when the patient-centered medical home model was implemented.                                  partment use for this group decreased 9.2 per-
                                                                                                                           cent, to a mean of 0.53 visits per patient in
                                                             home model was implemented (Exhibits 3                        the cohort (standard deviation: 1.083; 95%
                                                             and 4).                                                       confidence interval: 1.06, 1.11, p ¼ 0:001), a sig-
                                                                NewYork-Presbyterian plans to use the pre-                 nificant difference. During the same period,
                                                             vention quality indicators developed by the                   hospitalizations for the 2010 cohort dropped
                                                             Agency for Healthcare Research and Quality18                  from 1,503 to 1,416—a 5.8 percent decrease
                                                             to measure the quality of care provided by the                (p ¼ 0:25), which was not a significant dif-
                                                             hospital’s health care system and the overall                 ference.
                                                             health of community residents. The indicators                    Six months before the patient-centered medi-
                                                             are a set of metrics that measure hospital inpa-              cal home model was implemented, 1,971 patients
                                                             tient admissions for diagnoses of ambulatory                  in this cohort went to the emergency depart-
                                                             care sensitive conditions. Because there is a                 ment. They made 3,500 visits, or 1.8 visits per
                                                             one-year lag in New York State reporting of hos-              patient. However, in the six months after imple-
                                                             pital discharges, the indicators were not avail-              mentation, 143 fewer patients in the cohort
                                                             able for this population at the time this article             sought emergency department services. In addi-
                                                             was written.                                                  tion, they made only 1.7 visits per patient during
                                                                For the purpose of data analysis, we assigned              that period (Exhibits 3 and 4).
                                                                                                                              Although the early results of the NewYork-
                                                                                                                           Presbyterian Regional Health Collaborative are
          Exhibit 4                                                                                                        promising in terms of the number of visits to the
Hospitalizations Of Patients With Diabetes, Asthma, Or Congestive Heart Failure, NewYork-                                  emergency department, they represent only a
Presbyterian Hospital, 2010–11                                                                                             six-month period after the implementation of
                                                                                                                           the patient-centered medical home model. To
                                                                                                                           verify the collaborative’s success, we will need
     Number of visits or patients

                                                                                         Inpatient visits
                                                                                                                           data from a longer period and from more co-
                                                                                         Number of patients hospitalized
                                                                                                                           horts. The reductions in hospitalizations and
                                                                                                                           emergency department use described above cor-
                                                                                                                           relate with evidence from other patient-centered
                                                                                                                           medical home interventions.19

                                                                                                                           Discussion And Conclusion
                                                  Baseline                                                                 Financial Implications The NewYork-Presby-
                                                                                                                           terian Regional Health Collaborative has re-
SOURCE NewYork-Presbyterian Hospital disease registry. NOTES “Baseline” is hospitalizations in the                         quired a large commitment of staff resources
six months before October 2010, when the patient-centered medical home model was implemented.                              and involved the participation of more than

6                                   H ea lt h A f fai r s     October 2 011     3 0:10
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
140 multidisciplinary staff members at NewYork-        Exhibit 5
Presbyterian and Columbia University. Work
                                                      Disease Distribution Among Patients With Diabetes, Asthma, Or Congestive Heart Failure,
groups of ten to fifteen staff members at the         NewYork-Presbyterian Hospital, 2010
manager or director level were cochaired by a
senior hospital leader and senior physician             Disease                                                 Number of patients
and met biweekly for the first three phases.            Chronic condition (single disease)
   NewYork-Presbyterian incurred direct costs of        Asthma                                                  1,846
approximately $1.7 million during the first three       Congestive heart failure                                  437
phases of the collaborative. The costs were pri-        Diabetes                                                2,679
marily associated with implementing and main-           Chronic conditions (more than one disease)
taining the patient-centered medical homes.             Asthma, congestive heart failure                              48
                                                        Diabetes, asthma                                             423
However, the hospital expects to receive $3.3 mil-
                                                        Diabetes, congestive heart failure                           449
lion from New York State’s patient-centered             Asthma, diabetes, congestive heart failure                    81
medical home revenue enhancement fund. Addi-
tional costs include interpretation services,
which were covered by NewYork-Presbyterian’s          SOURCE New York-Presbyterian Hospital disease registry. NOTE Patients are those in the
overall operating budget; and information tech-       October 2010 cohort (N ¼ 5; 963), who had their first date of service in one of the seven
                                                      patient-centered medical homes between October 4 and October 31, 2010.
nology dashboards and registries, which were
funded by the hospital’s capital budget and
grants. This study could not quantify revenue
losses.                                               an extensive information technology infrastruc-
   Challenges Over the course of the NewYork-         ture, a wide variety of community-based health
Presbyterian Regional Health Collaborative, the       promotion and disease prevention projects, and
hospital faced numerous challenges. For exam-         collaboration with the independent local
ple, the initiative was a new concept for the hos-    physicians.
pital, involved many key stakeholders, and re-           Early results from the first six months after the
quired teamwork and cooperation to go from            implementation of the patient-centered medical
formulating strategies to executing them. The         home model show a significant reduction in the
hospital’s senior leaders fully supported the col-    number of emergency department visits by pa-
laborative. Other staff members’ collaboration        tients in the disease registry for diabetes melli-
was obtained by including people from various         tus, asthma, and congestive heart failure—three
disciplines across the institution in goal-           ambulatory care–sensitive conditions. Although
oriented work groups and training sessions            there was also a reduction in the number of hos-
   In addition, the patient-centered medical          pitalizations, that was not a significant change.
home required a change in clinical practice              The NewYork-Presbyterian Regional Health
and behavior. The development and use of dash-        Collaborative model is relevant to national
boards and a registry, in particular, involved the    health reform efforts because it illustrates an
implementation of multidisciplinary care teams        effective means of coordinating care for a poor,
and the institution of “previsit planning.” The       immigrant community. The model also included
teams established protocols to review the pa-         a targeted care intervention that provided sup-
tient’s care needs according to clinical guidelines   port and care coordination to patients who were
before the day of the visit. These new functions      considered cost outliers because of disease com-
and roles as well as other changes in the clinical    plexity and poor coordination of care by multiple
workflow required training and reinforcement.         providers.
   Conclusion       The     NewYork-Presbyterian         In sum, the NewYork-Presbyterian Regional
Regional Health Collaborative was designed to         Health Collaborative is a population-based
improve health, reduce disparities, and control       model that can uniformly improve quality for
costs by providing culturally competent, patient-     all patients and reduce disparities by improving
centered care; coordinating population health         overall access and quality. The initiative was
services; and targeting high-cost patients for        based on the commitment of an academic medi-
case management. The collaborative provides a         cal center to better serve urban populations fac-
model for quality health care and cost control to     ing social and cultural barriers, and the center’s
the thousands of US hospitals that are not part of    leadership and organizational capacity to plan,
integrated health delivery systems.                   guide, and sustain multifaceted efforts in col-
   The collaborative targeted the documented          laboration with community-based collaborators.
needs of and health care barriers faced by com-       It is replicable and scalable, and it could meet the
munity residents. It combined patient-centered        needs of many underserved communities across
medical homes into a medical village. This medi-      the United States. ▪
cal village is characterized by care coordination,

                                                                                     O cto b e r 20 1 1   30 : 1 0    H e a lt h A f fai r s   7
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

                       The authors are grateful for the          facilitated the hospital’s involvement       Ambulatory Care Network’s medical
                       contributions of New York State HEAL      and helped build bridges with local          directors, physicians, nurses, and staff
                       grants as well as the generosity of       community physicians. Rafael Lantigua,       have provided tireless and consistent
                       Pharmaceutical Research and               Steven J. Shea, and their Columbia           support. The authors thank the Robert
                       Manufacturers of America and the Heinz    University Medical Center colleagues         Wood Johnson Foundation and the
                       Family Philanthropies. The NewYork-       have helped build the initiative since its   Network for Multicultural Research on
                       Presbyterian (NYP) Regional Health        inception in 2008. Aurelia Boyer, NYP        Health and Healthcare for their support,
                       Collaborative Steering Committee          chief information officer, made key          mentoring, and inspiration in the
                       provided consistent support and           contributions, as did Tammy Tims, Karen      drafting of this article.
                       invaluable insights throughout. Robert    Zaranski, and the rest of the
                       Kelly, NYP president, championed and      information technology team. The NYP

                        1 Contemporary issues in medicine—         7 Carrillo JE, Carrillo V, Perez H,           613–20.
                          medical informatics and population         Salas-Lopez D, Natale-Pereira A,         14 Coleman EA, Parry C, Chalmers S,
                          health: report II of the Medical           Byron AT. Defining and targeting            Min SJ. The care transitions inter-
                          School Objectives Project. Acad Med.       health care access barriers. J Health       vention: results of a randomized
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                        2 Kaplan S. 2009 Ambulatory Care             562–75.                                     2006;166(17):1822–8.
                          Network annual quality and safety       8 National Committee for Quality As-        15 Crow C. It takes a village to build a
                          report. New York (NY): NewYork-            surance [home page on the Inter-            medical home. Medical Home News.
                          Presbyterian Hospital Ambulatory           net]. Washington (DC): NCQA;                2010;2(3):1, 6–7.
                          Care Network; 2010.                        [cited 2011 Sep 13]. Available from:     16 MyNYP.org [home page on the In-
                        3 Aguirre-Molina M. Community                http://www.ncqa.org                         ternet]. New York (NY): NewYork-
                          needs assessment for Washington         9 National Quality Forum. A compre-            Presbyterian Hospital [cited 2011
                          Heights–Inwood. New York (NY):             hensive framework and preferred             Sep 13]. Available from: https://
                          Columbia University, Mailman               practices for measuring and report-         mynyp.org/MyNYP.aspx
                          School of Public Health, Department        ing cultural competency [Internet].      17 To access the Appendix, click on the
                          of Population and Family Health;           Washington (DC): NQF; 2009                  Appendix link in the box to the right
                          2006. (Unpublished Report).                Apr [cited 2011 Sep 22]. Available          of the article online.
                        4 Census Bureau. Socioeconomic pro-          from: http://www.qualityforum.org/       18 Davies SM, McDonald KM,
                          file social characteristics—New York       Publications/2009/04/A_                     Schmidt E, Schultz E, Geppert J,
                          City: 1990 and 2000 census [Inter-         Comprehensive_Framework_and_                Romano PS. Expanding use of the
                          net]. Washington (DC): Census Bu-          Preferred_Practices_for_                    prevention quality indicators; report
                          reau; [cited 2011 Sep 12]. Available       Measuring_and_Reporting_                    of clinical expert review panel [In-
                          from: http://www.nyc.gov/html/             Cultural_Competency.aspx                    ternet]. Rockville (MD): Agency for
                          dcp/pdf/census/socionyc.pdf            10 Carrillo JE, Green AR,                       Healthcare Research and Quality;
                        5 Census Bureau. Socioeconomic pro-          Betancourt JR. Cross-cultural pri-          2009 Nov 7 [cited 2011 Sep 22].
                          file social characteristics—Manhat-        mary care: a patient-based approach.        Available from: http://www
                          tan Community District 1: 1990 and         Ann Intern Med. 1999;130:829–34.            .qualityindicators.ahrq.gov/
                          2000 census [Internet]. Washington      11 Billings J, Dixon J, Mijanovich T,          Downloads/Modules_Non_
                          (DC): Census Bureau; [cited 2011           Wennber D. Case finding for patients        Software/Modules%20
                          Sep 12]. Available from: http://           at risk of readmission to hospital:         Development%20Bullet/PQI%20
                          www.nyc.gov/html/dcp/pdf/                  development of algorithm to identify        Summary%20Report.pdf
                          census/1990-2000_mn_cd_profile             high risk patients. BMJ. 2006;333        19 Grumbach K, Grundy P. Outcomes of
                          .pdf                                       (7563):327.                                 implementing patient centered
                        6 Olson EC, Van Wye G, Kerker B,         12 Bodenheimer TS, Berry-Millett R.             medical home interventions: a re-
                          Thorpe L, Frieden TR. Take Care            Care management of patients with            view of the evidence from prospec-
                          Inwood and Washington Heights              complex health care needs. Prince-          tive evaluation studies in the United
                          [Internet]. 2nd ed. New York (NY):         ton (NJ): Robert Wood Johnson               States [Internet]. Washington (DC):
                          New York City Department of Health         Foundation; 2009 Dec 16.                    Patient-Centered Primary Care Col-
                          and Mental Hygiene; 2006 [cited        13 Naylor MD, Brooten D, Campbell R,            laborative; [updated 2010 Nov 16;
                          2011 Sep 22]. (NYC Community               Jacobsen BS, Mezey MD, Pauly MV,            cited 2011 Sep 22]. Available from:
                          Health Profiles). Available from:          et al. Comprehensive discharge              http://www.pcpcc.net/files/
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                          downloads/pdf/data/2006chp-                hospitalized elders: a randomized
                          301.pdf                                    clinical trial. JAMA. 1999;281(7):

8    Health A ffairs     O c to b er 2 0 1 1   30:10
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community

                                          such a high level of support and        where she is responsible for
                                          engagement from a provider              developing both clinical and
                                          community.”                             corporate strategic plans. She
                                            Carrillo, who is also an associate    obtained a master of business
                  J. Emilio Carrillo is   professor of clinical public health     administration degree from
                  vice president of       and clinical medicine at Weill          Columbia University’s Graduate
                  community health        Cornell Medical College, has been a     School of Business.
                  at NewYork-             senior fellow in residence at the
                  Presbyterian            Robert Wood Johnson Foundation
                                          and coauthored a National Quality
In this month’s Health Affairs,           Forum (NQF) paper on measuring
Emilio Carrillo and colleagues at         health care disparities. He serves                            Elaine M. Fleck is
NewYork-Presbyterian Hospital             on the NQF Care Coordination                                  an associate clinical
(NYP) in New York City describe           Steering Committee. For ten years                             professor of
the Regional Health Collaborative,        Carrillo was on the faculties of                              medicine at
                                          Harvard’s Medical School and                                  NewYork-
an integrated network of patient-
                                          School of Public Health. He                                   Presbyterian/
centered medical homes that aimed                                                                       Columbia.
to improve the health of the              received medical and master of
residents of a low-income                 public health degrees from                Elaine Fleck is an associate
neighborhood in upper Manhattan.          Harvard.                                clinical professor of medicine in
  By undertaking such changes as                                                  the Ambulatory Care Network of
targeting high-prevalence                                                         NYP/Columbia and director of
conditions and installing                                                         internal medicine for the network’s
integrated information systems, the                                               primary care practices. She
collaborative produced a decline in                          Nida Shabbir         received her medical degree from
the use of the emergency                                     Shekhani is a        Case Western Reserve University
department in Washington                                     manager in the       and her master of public health
Heights–Inwood, a predominantly                              Office of Strategy   degree from the Mailman School.
                                                             at NewYork-
Hispanic community, as well as a
5.8 percent decrease in                                      Hospital.
                                                                                                        Jaclyn Mucaria is
  Carrillo is vice president of             Nida Shekhani is a manager in
                                                                                                        senior vice
community health at NYP and has           the Office of Strategy at NYP. She                            president for
led the collaborative. “We wanted         holds a master’s degree in public                             ambulatory care
to make an academic medical               health policy and management                                  and patient-
center an enabler of health in the        from the Mailman School of Public                             centered services
community by collaborating with           Health at Columbia University.                                at NewYork-
the community,” he says. “You                                                                           Presbyterian
sometimes hear that working with
health care providers is like                                                       Jaclyn Mucaria is senior vice
herding cats, but that wasn’t our                                                 president for ambulatory care and
experience. Lots of people came                              Emme Levin Deland    patient-centered services at NYP.
together to make this work. The                              is senior vice       She received her master of public
[information technology]                                     president for        administration degree from New
programmers worked directly with                             strategy at          York University.
the doctors to create tools they                             NewYork-
needed and wanted. The doctors                               Presbyterian
themselves were very involved in
organizing and changing systems.            Emme Deland is senior vice
In fact, I have seldom encountered        president for strategy at NYP,

                                                                           Octo ber 2 011   3 0:10   Health Affa irs            9
A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Innovations In Care

                                              William Polf is senior vice               American Academy of Arts and
                                            president for external relations for        Sciences, Pardes has earned the
                                            NYP. He is responsible for                  Institute of Medicine’s Sarnat
                                            government relations, marketing,            International Prize in Mental
                     Robert Guimento is     media and public affairs,                   Health. He received his medical
                     vice president for     community affairs, grants, and              degree from the State University of
                     ambulatory care at     intellectual property. He holds a           New York’s College of Medicine.
                                            doctorate in American history from
                                            Syracuse University.

   Robert Guimento is vice
 president for ambulatory care at
 NYP, where he is responsible for
 overseeing financial, operational,                                                                        Steven J. Corwin is
                                                                Victor A. Carrillo is
 and strategic initiatives in                                                                              chief executive
                                                                the director of
                                                                                                           officer of NewYork-
 ambulatory care across all                                     community health
 campuses. He received a master’s                               development at
 degree in health administration                                NewYork-
 from Duke University.                                          Presbyterian              Steven Corwin was recently
                                                                                        named chief executive officer of
                                              Victor Carrillo is the director of        NewYork-Presbyterian Hospital. A
                                            community health development at             cardiologist and internist, he has
                     Steven Kaplan is
                                            NYP. He holds a master of public            been with the hospital since 1979
                     the chief medical
                     director and quality   administration degree from Pace             and joined its management team in
                     and patient safety     University.                                 1991. During his tenure as the
                     officer for                                                        hospital’s executive vice president
                     ambulatory care at                                                 and chief operating officer, he
                     NewYork-                                                           launched the NewYork-Presbyterian
                     Presbyterian                                                       Regional Health Collaborative.
                                                                                        Corwin obtained his medical degree
                                                                Herbert Pardes is
   Steven Kaplan is NYP’s chief                                                         from Northwestern University.
                                                                executive vice chair
 medical director and quality and                               of the board of
 patient safety officer for                                     trustees of
 ambulatory care. In this role he                               NewYork-
 oversees the clinical operational                              Presbyterian
 activities of fifteen primary care
 practices, seven school-based                 Herbert Pardes is executive vice
 health centers, and more than              chair of the board of trustees of
 sixty-five specialty care practices. A     NewYork-Presbyterian Hospital.
 practicing physician, he is board          Previously he was president and
 certified in emergency medicine.           chief executive officer of the
 Kaplan received his medical degree         hospital and the NewYork-
 from Weill Cornell Medical College.        Presbyterian Healthcare System.
                                            Nationally recognized for his broad
                                            expertise in education, research,
                                            clinical care, and health policy, he
                                            is an ardent advocate of academic
                     William A. Polf is     medical centers, humanistic care,
                     senior vice            and the power of technology and
                     president for          innovation to transform twenty-
                     external relations     first-century medicine.
                     at NewYork-
                                               An elected member of the
                                            Institute of Medicine and the

10      Health A ffairs     Octo ber 2 011    3 0:10
Program or Campaign            Goal and Description
Healthy Children in the     Regional Effort to Reduce
Heights                     Obesity in Collaboration with
                            Local Schools, Elected Officials
                            and Community Based
CHALK(Choosing Healthy      Social Marketing Campaign to
and Active Lifestyles for   Reduce Childhood Obesity;
Kids)                       Received Recognition by First
                            Lady Michelle Obama; supported
                            by New York City Department of
                            Health and Mental Hygiene
Healthy Schools – Healthy   Exercise and Nutrition School
Families                    Based in 7 Local Elementary and
                            Middle Schools; launched with
                            HRSA support
WIN for Asthma              Launched in 2003 with support
                            from Merck Foundation; Care
                            Management of Children with
                            Asthma Using Bi-Cultural
                            Community Health Workers
Pharmacy Assistance         Supports medication purchases
Program                     for uninsured patients; HRSA
Heart Failure Program       Support patients with Heart
(Heinz, PhRMA)              Failure with medically trained
                            Community Health Workers at home
                            and in the community
Seniors living with         Regional program to support
Diabetes (United Hospital   seniors with diabetes that links
Fund, Bristol-Meyers        with the New York City
Squibb)                     Department of Aging and
                            Community-Based Organizations
                            serving seniors
Building Bridges,           Collaborative comprised of
Building Knowledge &        Churches, Community Based
Building Health Coalition   Organizations, and academic
                            institutions. Targets diabetes
                            education and care in the
                            community. Funded by New York
                            State Department of Health and
                            HHS Office of Women’s Health.
                            Utilizes Community Based
                            Participatory Research
Turn to Us                 Childhood Violence Prevention,
                           Derek Jeter Foundation
Single Stop                Support entitlement program
                           enrollment; Governmental Health
                           Insurance; Robin Hood Foundation
Parish Nursing Program     Establishes Wellness Programs in
Local Industry Health      Bodegueros (small food shops);
Promotion and Disease      Hair Salons and Barber Shops;
Prevention Programs        Livery Cab Drivers; Domestic
Reach Out and Read         Promotes early literacy;
                           Bilingual and bicultural
School-Based Health        The SBHCs operated by the Center
Centers (SBHC)             for Community Health and
                           Education provide a
                           multidisciplinary service model
                           that integrates primary care,
                           mental health counseling and
                           health education in seven NYP
                           ACN sites which serve 15
                           Northern Manhattan intermediate
                           and high schools. The sites are
                           located at the George Washington
                           Educational Campus, the Stitt
                           Campus, the 143 Campus and the
                           Inwood Community Campus in
                           Washington Heights and the Percy
                           Sutton Campus, Thurgood Marshall
                           Academy and Promise Academy in
                           Central Harlem. Student patients
                           incur no charges for the care
                           that they receive from licensed
Table 2: NewYork-Presbyterian Disease Prevention
Source: The Community of Care: Serving the Needs of the
Community, NewYork-Presbyterian Hospital. 2008. Available
from: http://nyp.org/csp.
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