Chronic Disease Prevention & Management

Health for Life

Health4Life (H4L) is a family-centered lifestyle intervention program for overweight children and adolescents ages 2-18 and their families. The program provides a safe and supportive environment for patients and families and empowers them to make healthier lifestyle choices through dietary changes and increased physical activity. Children aged 7-18 may join weekly virtual exercise classes. Parents can engage in a 10-week nutrition education and support group program.

Key Accomplishments & Outcomes for 2022

500+

referrals to the clinical program

30

families attended nutrition education classes

71%

attendance at clinical visits; families now prefer virtual visits

141

interactions in 33 virtual exercise classes

18

interactions in four in-person summer activity programs

30

caregiver nutrition education classes for caregivers were offered with 89% attendance. Every family received free fruit and vegetable deliveries to their homes for six months through the Tangelo program.

NYP Hudson Valley Hospital Teaching Kitchen provided

cooking demonstrations

Eating Better, Living Better

I failed so many times trying to make my daughter eat new foods. After just one Zoom visit with you, I was fascinated by the possibility of finally getting her to eat better. I felt overjoyed when I saw her eating vegetables and other types of food. The way your entire team worked with her and helped us try different kinds of food, vegetables, and exercise was amazing. Seeing my baby enjoying broccoli, I cried with happiness. Thank you for not only changing my daughter’s life, but the lives of my entire family.

Health4Life parent

Key Accomplishments & Outcomes for 2022

5,000

members reached through BBKH coalition initiatives

20%

increase in coalition membership

100+

Mental Health First Aid (MHFA) trainings for adults who work with adults and youth

More than

80

participants attended the Sixth Annual Clergy Summit entitled “Mental Health Equity and Advocacy for a Healing Community,” held virtually in November 2022

Scholarship funds

for a BBKH faith leader to become an MHFA trainer

Monthly meetings

with faith leaders to provide education and resources identified by the member-driven planning committee

Provided

in-person safety trainings

in hands-only CPR, active shooter, de-escalation, EpiPen use, Stop the Bleed, and transportation

Health fairs,
in-house trainings, and pop-up clinics

led by coalition members

Building Bridges, Knowledge & Health Coalition

The Building Bridges, Knowledge and Health (BBKH) coalition works with faith and community-based organizations to reduce racial and ethnic health disparities and enhance the well-being of residents in Northern Manhattan, Harlem, and the Bronx. Church members are valuable conduits of good health, responding to community health needs and implementing interventions to achieve meaningful results.

Man leading a discussion group

One Pastor’s Story

I am the pastor of St. Helena Catholic Church in the Bronx and our parish is a member of the BBKH coalition. I believe that BBKH’s move to virtual meetings has significantly increased member participation and greatly expanded the list of potential partners. The meetings are always informative. Last September, St. Helena hosted a BBKH in-person presentation focusing on what to do in an active shooter situation, a segment on Stop the Bleed, and another on hands-only CPR. Each topic could easily have been a full workshop in itself. Participants were interested, engaged, and asked many relevant questions. I look forward to actively participating in future BBKH meetings and events.

Rev. David Powers, Sch.P., Pastor, St. Helena’s Church

Center for Community Health Navigation

Since 2005, the Center for Community Health Navigation (CCHN) works to support the health and well-being of patients through the delivery of culturally sensitive peer-based support in the emergency department, inpatient, outpatient, and community settings.

Key Accomplishments & Outcomes for 2022

CCHN Pediatric CHW Program

Between September 2006 and December 2022, CHWs enrolled

1,565

caregivers of children with poorly managed asthma

Among graduates of the program, hospitalizations decreased by

76%

ED visits declined by 68%, and

97%

of caregivers felt able to manage their child’s asthma

Between July 2018 and December 2022, nearly

84%

of caregivers of children with special healthcare needs reported reduced or similar levels of stress upon discharge compared to intake, 95% reported that they knew how to access care for their children, and 91% felt in control of their child’s condition

Emergency Department-Based Patient Navigator Program

From December 2008 to December 2022, ED-based patient navigators supported

339,440

patients

76%

of the 178,553 patients for whom an appointment was scheduled attended it

93%

of the 88,583 patients without a primary care provider had an appointment with a new provider upon discharge

CCHN Pediatric CHW Program

Between June 2017 and December 2022, CHWs supported

1,317

participants enrolled in the Adult CHW Program

Among graduates

89%

met their medication management goal

Among graduates

90%

met their patient navigation goal and 89% met their social determinants goal

A Fresh Start

During an interaction between a CHW and the mother of an 11-year-old child and a newborn, the CHW learned that the mother was unable to afford a crib, car seat, and clothes for her newborn. The CHW referred the mother to various community programs so she could receive the resources and support she needed. Through this program, the mother obtained a car seat and a crib. She also received resources for diapers and clothing for the newborn. All of this was possible thanks to the help of the CHW and teamwork. The mother was very grateful.

Key Accomplishments & Outcomes for 2022

17,528

individuals participated in Food FARMacy programs

915

patients received Fruit and Vegetable Prescriptions

800

students and 11 teachers at PS48M

284

community leaders attended capacity-building events: five webinars, seven consulting opportunities, four affinity group meetings, and a conference

Choosing Healthy & Active Lifestyles for Kids

NewYork-Presbyterian’s Choosing Healthy & Active Lifestyles for Kids (CHALK) increases access to healthy lifestyles for children and families by focusing on nutrition and physical activity and collaborating with community-based organizations, early childhood centers, public schools, emergency food providers, and healthcare teams. The CHALK model was developed as an obesity prevention program in Northern Manhattan and has expanded to other New York City communities and Westchester County.

CHALK initiatives include:

  • Food FARMacy
  • Youth Market
  • CHALK School Partnerships and CHALK Jr focus
  • The Capacity Building Initiative and CBO Mini-Grant Program

3,190

students and parents/caregivers were reached through CHALK schools and CHALK Jr

$35,500

in mini-grants were awarded to 11 community-based organizations

1,453

people attended 83 nutrition and physical activity workshops

4,518

community members were reached through mini-grant projects

1,073

interactions took place at open streets and health fairs

68

pediatric medical residents attended community health and obesity prevention workshops

From Participant to Employee

I transitioned from being a Nido participant to an employee. Being part of the distribution team has been a positive and wonderful experience. I enjoy being one of the friendly faces the families get to see every time they pick up their pantry boxes. It makes my soul happy to see them receive the fresh produce that they need.

Mobile market coordinator at Nido de Esperanza, a CHALK partner committed to supporting the first 1,000 days of a child’s life

Manhattan Cancer Services Program

The aim of the Manhattan Cancer Services Program is to reduce cancer outcome disparities in at-risk, uninsured community residents. Program staff identify communities at high risk for cancer mortality who are under or uninsured and have low cancer screening rates. In collaboration with community and faith-based organizations, key stakeholders and decision makers provide community-based education and enrollment. Staff screen individuals using the New York State Department of Health assessment to identify and overcome barriers to care and provide no-cost screening and diagnostic services in Manhattan.

Key Accomplishments & Outcomes for 2022

Expanded
provider sites

with a special focus on federally qualified health centers

Provided

52

psychoeducational events attended by 1,690 community members

2,808

people screened for breast, cervical,
or colorectal cancer

Diagnosed

11

breast cancers

46

cervical cancers

1

colorectal cancer

Accessing Breast Cancer Care

An uninsured woman diagnosed with breast cancer was living in temporary housing, was food insecure, and was unable to use the subway or bus to get to her treatments. She was overwhelmed by her diagnosis. She applied for and was accepted for housing at Hope Lodge, but there was no available room when she needed it. Her daughter arrived from the Dominican Republic and engaged extended family members to help with housing in Queens and support for activities of daily living. We helped her apply for no-cost food delivery from a local food pantry and connected her with transportation through Access-a-Ride. She has been receiving treatment and has been supported by a nurse case manager, who continues to provide her with emotional support and helps her navigate barriers.

Key Accomplishments & Outcomes for 2022

Bimonthly virtual and in-person

educational programs

for the Bowery Mission and HELP USA women’s shelter

Pop-up clinics

for asylum seekers in New York City, homeless outreach events, and PCR testing for the Washington Heights community

Relaunch of

in-person health fairs & targeted events

such as the Domestic Workers Health Fair and Harlem Pride event

133+

people received Mental Health First Aid (MHFA) training

3,000+

community members impacted at targeted health screening events, community health fairs, and pop-up clinics

1,100+

flu and COVID-19 vaccinations administered

Community Outreach Program

The Community Outreach Program promotes overall wellness and disease prevention through educational and screening activities that facilitate early detection and intervention, with the ultimate goal of reducing health disparities. Staff connect people to primary and specialty care as well as other supportive resources. Community members have access to free screenings, vaccinations, and counseling and are empowered through a myriad of educational workshops.

Woman in a wheelchair showing a vaccinated arm

Supporting Health at the Church of the Epiphany

At the Church of the Epiphany on the Upper East Side, the Outreach Program staff ran monthly health screening events for dinner guests before the pandemic. We collaborated with NewYork-Presbyterian/Weill Cornell nursing staff to provide blood pressure screenings, reading glasses, hands-only CPR training, and counseling on healthy lifestyle choices. We counseled one gentleman on how to lower his blood pressure and stay compliant with his medications and his doctor visits. Over time, his blood pressure improved, he lost weight, and he felt better about his well-being. We rewarded him with a portable machine to monitor his blood pressure at home. His entire disposition changed as he moved toward improved health. Throughout the pandemic, Outreach Program staff continued to support the church by providing temperature screenings for their pick-up meal service. The team was happy to provide assistance during the church’s “new normal.”

Waiting Room as a Literacy & Learning Environment

The Waiting Room As a Literacy & Learning Environment (WALLE), an initiative of the NewYork-Presbyterian Ambulatory Care Network (ACN), addresses the social determinants of health through a twofold approach: improving health literacy through targeted health education and empowering patients to connect with resource referrals to meet their social needs. WALLE helps medically underserved patients who are primarily from Washington Heights, Inwood, and the Bronx, most of whom are native Spanish speakers. Bilingual volunteers are trained in motivational interviewing skills, the tenets of health literacy, and the Transtheoretical Model. WALLE staff members link patients with free or low-cost community resources, assist patients with the completion of medical forms, and recruit interns to serve ACN patients.

Uptown Hub Group

Key Accomplishments & Outcomes for 2022

Successfully concluded the

CMMI Accountable Health Communities grant

and expanded New York State Department of Health (NYSDOH) screening and closed loop navigation for low- and rising-risk patients

Reached out to 21,747 patients and connected with

13,862

of them

Administered

11,392

NYSDOH screenings across ACN sites

41

health field students from 30+ higher learning institutions were WALLE interns

WALLE interns collectively served over

5,600

hours by helping to screen patients and providing 7,811 tailored lists of free or low-cost community resources