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An ongoing NewYork-Presbyterian initiative to improve the health of residents in Washington Heights and Inwood has led to a reduction in emergency room visits and hospitalizations related to diabetes, asthma and congestive heart failure.

Results from the first six months of the NewYork-Presbyterian Regional Health Collaborative are published in the October edition of the journal Health Affairs as part of a special issue dedicated to addressing health disparities.

"The predominantly low-income and immigrant communities of Washington Heights and Inwood have struggled with high rates of asthma, diabetes, heart disease and depression, says lead author J. Emilio Carrillo, M.D., vice president of community health at NewYork-Presbyterian Hospital and associate professor of clinical public health and clinical medicine at Weill Cornell Medical College. "The NewYork-Presbyterian Regional Health Collaborative is addressing this challenge through a unique and proactive approach that connects providers, coordinates care and communicates with patients in a culturally competent manner.

"So far the results have been very encouraging. A reduced need for emergency medical attention or hospitalization means more patients are getting the preventive and ongoing care they need, continues Dr. Carrillo.

NewYork-Presbyterian serves more than 60 percent of the 270,000 residents of Washington Heights–Inwood, a community geographically bounded by the Hudson and Harlem Rivers. Most of the area's residents are poor, Spanish-speaking immigrants who face socioeconomic and health disparities compared with residents of other parts of New York City.

Beginning in 2008, NewYork-Presbyterian, in association with Columbia University Medical Center, developed the NewYork-Presbyterian Regional Health Collaborative. The innovative initiative goes beyond the established patient-centered medical home model, creating what the authors call a medical village, defined as a series of medical homes and other community resources connected via IT infrastructure. Following initial assessment and strategy phases, the full program was launched in October 2010.

The program centers around the Hospital's Ambulatory Care Network, which includes seven stand-alone community health center practices and seven school-based centers in the Washington Heights — Inwood area but also connects with independent physicians and home health care providers in the community.

The National Committee for Quality Assurance has designated these seven ambulatory care centers as Level 3 patient-centered medical homes, making NewYork-Presbyterian one of only a very few U.S. academic medical centers to have a large network of Level 3 patient-centered medical homes. The Level 3 designation is the highest awarded for patient-centered medical homes and is based on specific criteria that reflect an evidence-based and coordinated care approach.

"The NewYork-Presbyterian Regional Health Collaborative is relevant to health reform and may serve as a model for other hospitals across the country because it illustrates an effective means of coordinating care for a poor, immigrant community," says Dr. Carrillo. "By making sure that patients get the care they need outside the hospital, we are improving the health of the community. At the same time, we are freeing up resources to better treat patients when they have a serious and life-threatening medical need."

"The success of this program is a testament to the Hospital's longstanding commitment to the health of the communities we serve, as well as to an unprecedented collaboration between NewYork-Presbyterian, Columbia University, government agencies and community physicians and organizations," says senior author Steven J. Corwin, M.D., CEO of NewYork-Presbyterian Hospital.

Additional authors include Nida Shabbir Shekhani, manager in the Office of Strategy at NewYork-Presbyterian Hospital; Emme Levin Deland, senior vice president for strategy at NewYork-Presbyterian Hospital; Elaine M. Fleck, M.D., associate clinical professor of medicine in the Ambulatory Care Network of NewYork-Presbyterian Hospital/Columbia University Medical Center; Jaclyn Mucaria, senior vice president for ambulatory care and patient-centered services at NewYork-Presbyterian Hospital; Robert Guimento, vice president for ambulatory care at NewYork-Presbyterian Hospital; Steven Kaplan, M.D., chief medical director and quality and patient safety officer for ambulatory care at NewYork-Presbyterian Hospital; William A. Polf, senior vice president for external relations for NewYork-Presbyterian Hospital; Victor A. Carrillo, director of community health development at NewYork-Presbyterian Hospital; and Herbert Pardes, M.D., executive vice chairman of the board of trustees at NewYork-Presbyterian Hospital.

The NewYork-Presbyterian Regional Health Collaborative is funded, in part, by New York State HEAL grants and through the generosity of Pharmaceutical Research and Manufacturers of America, Heinz Family Philanthropies, Robert Wood Johnson Foundation and the Network for Multicultural Research on Health and Healthcare.

NewYork-Presbyterian Hospital

NewYork-Presbyterian Hospital, based in New York City, is the nation's largest not-for-profit, non-sectarian hospital, with 2,409 beds. The Hospital has nearly 2 million inpatient and outpatient visits in a year, including 12,797 deliveries and 195,294 visits to its emergency departments. NewYork-Presbyterian's 6,144 affiliated physicians and 19,376 staff provide state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine at five major centers: NewYork-Presbyterian Hospital/Weill Cornell Medical Center, NewYork-Presbyterian Hospital/Columbia University Medical Center, NewYork-Presbyterian/Morgan Stanley Children's Hospital, NewYork-Presbyterian/The Allen Hospital and NewYork-Presbyterian Hospital/Westchester Division. One of the most comprehensive health care institutions in the world, the Hospital is committed to excellence in patient care, research, education and community service. NewYork-Presbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report. The Hospital has academic affiliations with two of the nation's leading medical colleges: Weill Cornell Medical College and Columbia University College of Physicians and Surgeons.