Search

The Washington Heights-Inwood section of Manhattan is a predominantly poor Hispanic community with disproportionately high rates of chronic disease, including asthma, diabetes, and congestive heart failure. In October 2010, NewYork-Presbyterian Hospital, in association with the Columbia University Medical Center, launched an integrated network of patient-centered medical homes that were linked to other providers and community-based resources and formed a “medical village.” Three years later, a study of 5,852 patients who had some combination of diabetes, asthma, and congestive heart failure found that emergency department visits and hospitalizations had been reduced by 29.7 percent and 28.5 percent, respectively, compared to the year before implementation of the network. Thirty-day readmissions and average length-of-stay declined by 36.7 percent and 4.9 percent, respectively. Patient satisfaction scores improved across all measures. Financially, NewYork-Presbyterian experienced a short-term return on investment of 11 percent. Some of the gain was a result of increased reimbursements from New York State. Nonetheless, these findings demonstrate that academic medical centers can improve outcomes for poor communities by building regional care models centering on medical homes that incorporate patient-centered processes and are linked through information systems and service collaborations to hospitals, specialty practices, and community-based providers and organizations. [ABSTRACT FROM AUTHOR]

Communities of poor, low-income immigrants with limited English proficiency and disproportionate health burdens pose unique challenges to health providers and policy makers. New York-Presbyterian Hospital developed the Regional Health Collaborative, a population-based health care model to improve the health of the residents of Washington Heights-Inwood. This area is a predominantly Hispanic community in New York City with high rates of asthma, diabetes, heart disease, and depression. New York-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, and introduce integrated information systems across care sites. The first six months of the program demonstrated a significant 9.2 percent decline in emergency department visits for ambulatory care-sensitive conditions and a 5.8 percent decrease in hospitalizations that was not statistically significant. This initiative offers a model for other urban academic medical centers to better serve populations facing social and cultural barriers to care. [ABSTRACT FROM AUTHOR]