Syed Ali Husain, MD, MPH, MA, FASN (CUIMC); Harry Reyes Nieva, PhD, MAS (CUIMC); Karthik Natarajan, PhD (NYP); Sumit Mohan, MD, MPH, FASN (CUIMC); Miko Yu, MPH (CUIMC)

Kidney transplantation offers better survival, quality of life, and long-term cost benefits compared to dialysis, yet most end-stage kidney disease patients in the U.S. never get waitlisted for a transplant. Disadvantaged groups, including minorities, women, and those with lower education and socioeconomic status, face even lower waitlisting rates. A crucial step in improving equity is facilitating timely completion of kidney transplant evaluations (KTEs), which are necessary for determining eligibility for the waiting list. KTEs are complex, often requiring over ten visits, and there are significant disparities in completion rates. This project aims to use machine learning to identify candidates at risk of delayed or incomplete KTEs. The team will develop integrated checklists and dashboards in electronic medical records to enable early intervention, thus optimizing pre-transplant resources and enhancing equity in KTE completion.

Lynn Jiang, MD (WCMC); Peter A.D. Steel, MA, MBBS, FACEP (WCMC); Natalie Benda, PhD (CUIMC); Radhika Sundararajan, MD, PhD (WCMC)

Each year, over 80% of emergency department (ED) visits end with patients being discharged home. This transition is critical, as patients must understand discharge instructions and adhere to post-ED care plans. However, current discharge processes often fall short, leading to unplanned revisits and hospitalizations, especially for vulnerable limited-English proficiency (LEP) patients who face unique barriers to health care access and health literacy.

Transforming the ED discharge process is essential for improving safety and health equity in post-ED outcomes. This project will use inclusive, participatory design and implementation mapping to create a patient-centered discharge process. The team will engage recently discharged ED patients and frontline providers to redesign the current system and assess the new process's impact on clinical outcomes. Their long-term goal is to enhance the quality of ED discharges and improve equity in post-ED outcomes, particularly for LEP populations.

Melissa Beauchemin, PhD (CUIMC); Claire Sathe, MD, JD (CUIMC); Dave Destephano, MPH (CUIMC); Rhea Khurana, BS (CUIMC); Nat Benda, PhD (CUIMC); Justine Kahn, MD, MPH (CUIMC); Melissa Accordino, MD, MS (CUIMC); Dawn Hershman, MD, MS (CUIMC); Shoshana Rosenberg, ScD (WCMC); Laura Pinheiro, PhD, MPH (WCMC)

This project aims to improve technology-based screening for unmet health-related social needs (HRSNs) among cancer treatment patients. The team will use a learning health system (LHS) approach to identify patients with unmet needs and connect them to appropriate interventions and community resources. They will expand an electronic dashboard to organize HRSN screening data across the NewYork-Presbyterian system and use mixed methods to explore patient and caregiver perceptions of HRSN screening and access to interventions. Ultimately, the goal is to enhance equitable cancer care delivery and improve health outcomes.

Kalliope Tsirilakis, MD; Perdita Permaul, MD, FAAAAI, FAAP; Maria D’Urso, MSN, MBA, RN, FACHE; Rachel Schwartz, RN ,MSW, MPH; Zenna Solomon, MD

Cynthia X Pan MD (PI) (WC, NYPQ); Kimberly Bloom-Feshbach MD. (WC); Melissa Patterson MD (CUIMC); Milagros D. Silva MD (WC); Andrea Card, MD (WC); Robyn Winsor, MD (CUIMC); Kerrianne P. Page, MD (CUIMC)

In the U.S., hospice care is significantly underutilized by racial and ethnic underrepresented groups and individuals with low English proficiency. To address these disparities, the GOComm-PC initiative will engage the community to develop patient-centered programs. Building on successful goals of care communication training for inpatient clinicians, the initiative will adapt this training for primary care, emphasizing culturally responsive skills to improve hospice utilization among underrepresented groups.

By integrating these discussions into routine ambulatory care, GOComm-PC aims to empower patients to understand advance care planning and hospice options, facilitating shared decision-making that aligns with their values. This initiative will prepare clinicians for meaningful conversations about medical decisions, supporting NewYork-Presbyterian Medical Group’s objectives for Medicare Annual Wellness Visits and increasing appropriate hospice use.