Regional Health Collaborative

The NewYork-Presbyterian Hospital
Regional Health Collaborative

A population-based model of health and health care encompasses the ability to:

assess the health needs of a specific population
implement and evaluate interventions to improve the health of the population
provide care for individual patients in the context of the culture, health status, and health needs of the population.

New York-Presbyterian Hospital, in association with Columbia University Medical Center, has developed the Regional Health Collaborative – a population-based, collaborative model of regional health planning and care coordination designed to measurably improve health and reduce disparities. The initiative could serve as a model for delivering health care to underserved communities across the nation.

Background

Recognizing that the residents in its community were experiencing gaps in care, unmet needs, and escalating health costs, NewYork-Presbyterian initiated a major review of the health delivery model in 2008. The goal was to create a system of care modeled on the concept of population-based health care. The hospital wanted the system to meet identified needs of the community, improve access to care, and coordinate care for each patient, wherever he or she received care.

The hospital reviewed its services and conducted a formal health needs assessment of the community, using existing health and census data and feedback from staff physicians and nurses in NewYork-Presbyterian's community groups, as well as physicians unaffiliated with NewYork-Presbyterian. The hospital and its collaborators developed a rational, coordinated system to deliver care to the community and agreed to monitor progress through measurable outcomes.

The Washington Heights-Inwood Initiative

The transformed system launched in October 2010 through the NewYork-Presbyterian Regional Health Collaborative/Washington Heights-Inwood Initiative. This initiative encompasses the entire neighborhood of Washington Heights-Inwood, in upper Manhattan, to help it improve the health of this community by reducing health disparities at both the individual and population levels. The goal is to uniformly enhance and align health care systems throughout the neighborhood to improve overall access to care and quality of care for the entire population.

Washington Heights-Inwood is a predominantly Hispanic community with high rates of asthma, diabetes, and heart disease. NewYork-Presbyterian created an integrated network of patient-centered medical homes to form a "medical village" linked to other providers and community-based resources. The initiative set out to document the priority health needs of the community, target high-prevalence conditions, improve cultural competence among providers, introduce integrated information systems across care sites, and coordinate care across the continuum.

The first six months of the program resulted in a 9.2-percent decline in emergency department visits for ambulatory care-sensitive conditions, and a 5.8-percent decrease in hospitalizations (the latter being a statistically non-significant change).

A Model for National Care

The NewYork-Presbyterian Regional Health Collaborative model is relevant to national health reform efforts because it illustrates an effective means of coordinating care for poor, immigrant communities. It also includes a targeted care intervention that provides support and care coordination for patients who were considered "cost outliers" because of disease complexity and fractured care. This model is replicable and scalable, and could meet the needs of many underserved communities across the United States.