At the Intersection of Health, Health Care and Policy Cite this article as: J. Emilio Carrillo, Victor A. Carrillo, Robert Guimento, Jaclyn Mucaria and Joan Leiman The NewYork-Presbyterian Regional Health Collaborative: A Three-Year Progress Report Health Affairs, 33, no.11 (2014):1985-1992 doi: 10.1377/hlthaff.2014.0408
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Collaborating For Community Health By J. Emilio Carrillo, Victor A. Carrillo, Robert Guimento, Jaclyn Mucaria, and Joan Leiman 10.1377/hlthaff.2014.0408 HEALTH AFFAIRS 33, NO. 11 (2014): 1985–1992 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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The NewYork-Presbyterian Regional Health Collaborative: A Three-Year Progress Report
J. Emilio Carrillo is vice president of community health, NewYork-Presbyterian Hospital, in New York City.
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
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isadvantaged communities, whose residents face numerous social and cultural barriers, often experience gaps in health care. They also pose significant challenges to the academic medical centers that provide care to the residents of these communities because the financial, cognitive, and structural barriers that residents face often lead to decreased screening rates, delayed care seeking, and lack of treatment.1 The Washington Heights–Inwood community, located at the northern tip of Manhattan, is a disadvantaged community. Most of its residents
Victor A. Carrillo (vac9009@ nyp.org) is director of community health development at NewYorkPresbyterian Hospital. Robert Guimento is vice president of ambulatory care at NewYork-Presbyterian Hospital. Jaclyn Mucaria is senior vice president of ambulatory care and patient-centered services at NewYork-Presbyterian Hospital. Joan Leiman is a special lecturer in health policy and management and in international and public affairs at the Mailman School of Public Health, Columbia University, in New York City.
are Spanish-speaking immigrants, and nearly one-fourth have incomes below the federal poverty level (Exhibit 1). They face socioeconomic and health disparities compared to the rest of New York City.2–4 More than 60 percent of the community’s estimated 205,000 residents receive their care from NewYork-Presbyterian Hospital, and more than 40 percent do so through the hospital’s ambulatory practices.5,6 In 2008, recognizing that the health needs of this predominantly low-income and Hispanic population were going unmet, NewYorkPresbyterian embarked on a population health initiative. After conducting a formal health November 2014
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H ea lt h A f fai r s
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Collaborating For Community Health Exhibit 1 Demographic Characteristics Of Washington Heights–Inwood And New York City, 2010–12 Characteristic Race or ethnicitya Hispanic White non-Hispanic African American non-Hispanic Asian or Pacific Islander
Washington Heights–Inwood
New York City
71.0% 17.6 7.3 2.5
28.6% 33.3 25.5 12.7
48.9 67.9 19.9
37.3 24.7 10.5
$39,535 15.6% 23.6
$50,711 11% 20.8
Literacy and education Born outside the US Speaks Spanish at home Less than 9th grade education
gan October 4, 2010. Data for the first six-month period on a cohort of nearly six thousand patients who enrolled in October 2010 were promising. The data demonstrated a significant 9.2 percent decline in emergency department (ED) visits for conditions that could be treated on an ambulatory basis and a 5.8 percent decrease in hospitalizations, which was not significant).7 This article reports on the outcomes of the same cohort of patients three years after implementation (see online Appendix Exhibits A1 and A2 for patients’ demographic characteristics and chronic disease distribution, respectively).8
Economic status Median household income Unemployment rate Percent of population below poverty level
SOURCE Authors’ analysis of data from the New York City Department of Health and Mental Hygiene. a Percentages do not sum to 100 because of “other” or “unspecified” responses.
needs assessment of the community and reviewing the services the hospital offered residents, NewYork-Presbyterian joined forces with the physicians and schools of the Columbia University Medical Center and with community-based providers and organizations to reinvent its ambulatory health care delivery model. The goal was to reduce health disparities at both the individual and population levels.1,2 In October 2010 the NewYork-Presbyterian Regional Health Collaborative was launched. It was a rational, coordinated system of care delivery that was intended to measurably improve the health of the Washington Heights–Inwood population. Unlike integrated delivery systems such as Kaiser Permanente Southern California, which operate under central governance, the NewYorkPresbyterian Regional Health Collaborative consists of independent entities. The collaborative contains a hospital and a university faculty practice, which—together with community physicians, home care agencies, community-based organizations, and other schools in Columbia University—share the goal of measurably improving the health of the community. Evidence-based strategies, information technology (IT), and cultural competency are used to reorganize care delivery around the needs of patients and families. NewYork-Presbyterian developed care protocols and information systems and conducted extensive training for physicians, nurses, and other care team members in June and July 2010, before piloting the model starting in August 2010. Full implementation of the collaborative be1986
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The Care Model The centerpiece of the NewYork-Presbyterian Regional Health Collaborative was the conversion of seven ambulatory care centers in the community into patient-centered medical homes. All seven have received level 3 certification (the highest level available) from the National Committee for Quality Assurance. Since our initial report,8 two medical homes have merged their services into one facility, leaving a total of six. The Community Health Team The medical homes provide care through interdisciplinary community health teams that are led by primary care physicians and that include nurse care managers, primary care nurses, nurse practitioners, nurse disease managers, social workers, nutritionists, and pharmacists. Also part of the team are members of a new generation of culturally competent front-line workers from the community who are bilingual and whose cultural backgrounds are similar to those of the community residents served by the practice. These front-line workers include medical assistants, patient registrars, and community health workers. In many other settings, community health workers are adjuncts to the care team and are not directly embedded in its day-to-day functions. However, the NewYork-Presbyterian Regional Health Collaborative’s community health workers are subcontracted from collaborating community-based organizations and are integrated into interdisciplinary community health teams.9,10 Care roles and responsibilities were realigned for team care delivery, and front-line workers participate in weekly interdisciplinary community health team meetings and daily previsit conferences (“huddles”) as needed. They also receive training in care processes and the use of information systems tools. Hospital residents in internal medicine, pediatrics, and family medicine participate in the care teams. Residents are trained in care coordination, transitions of care and care continuity,
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Patient-family advisory councils were created to provide channels to identify areas of importance to improve patient satisfaction and care.
and patient-based cross-cultural communication.11 The weekly interdisciplinary community health team meetings have about twelve participants and last one hour. The meetings are chaired by a primary care physician and are facilitated by a nurse care manager, who searches the hospital’s electronic disease registries to identify high-risk patients who have a high number of ED visits, hospital admissions, or both or who have abnormal clinical indicators for one or more chronic conditions. The team discusses these at-risk patients and formulates plans for reaching out to them and caring for them. Each day a subset of the team conducts “previsit planning” to help prepare for patients’ visits by anticipating what screenings, referrals, and educational activities will be necessary. This helps improve the efficiency and effectiveness of the visit. The electronic registries and patient care dashboards—components of the electronic medical record that summarize the patient’s chronic conditions, laboratory results, and required tests and screenings—provide the necessary data. Nurse disease managers help educate patients with diabetes about managing their condition. In late 2011 the medical homes implemented a Diabetes Self-Management Education Program that was based on a standardized curriculum endorsed by the American Association of Diabetes Educators. Additionally, a community-based program called Together on Diabetes—a collaboration involving a number of agencies—supports and educates seniors with diabetes who reside in Washington Heights–Inwood. Care Management Of High-Risk Patients With Complex Conditions To better manage high-risk patients who have multiple comorbidities and face a number of sociocultural challenges, a medical home–based Targeted Care
Initiative was implemented in July 2011. In this initiative, electronic disease registries are used to identify patients with a diagnosis of diabetes, congestive heart failure, asthma, or some combination of the three who have had high use of NewYork-Presbyterian during the preceding twelve months—that is, on at least three occasions they have either visited the ED or been admitted to the hospital. Nurse care managers review the patients’ records to assess the potential impact of care management services on the patients’ care. In addition, the medical home primary care providers refer patients with complex conditions who are not following their care plans to the care management program for further assessment and intervention by the nurse care managers. These managers are embedded in the interdisciplinary community health team and are supported by a specialized subteam of care management assistants, pharmacists, psychiatric social workers, and community health workers. Protocols have been established to provide the highest-risk patients with close care management, to follow them with less intensity as they improve, and to resume more intensive support if they falter. The highest-risk patients are closely tracked and are offered additional support by community health workers, who provide outreach and education in the community as well as in the patient’s home. Improving The Patient Experience The medical homes became an integral part of NewYork-Presbyterian’s efforts to promote patient-centered care and improve patient experience. Each medical home also participated in the hospital’s We Put Patients First initiative, a program that was launched in 2007 to deliver the best clinical care, focusing on every interaction with a patient and adhering to the highest standards of quality and patient safety. The medical homes adapted elements of the initiative and made them part of the homes’ team processes and patient education activities. Interdisciplinary community health teams also developed Making It Better Plans. These served as year-long road maps to help the medical homes achieve specific goals, such as improving communication when greeting a patient and promoting the smoother flow of patients through their visits to minimize wait times. Patient-family advisory councils were created to provide channels for patients and their families to identify areas of importance to improve patient satisfaction and care. Patient-centered care committees were established at each medical home and held regular meetings to share data and information. The committees also set goals and targets to institutionalize best practices; N ov em b e r 2 0 1 4
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Collaborating For Community Health promote employee recognition; and improve teamwork, communication, and respect for the patient. “Patient rounding”—that is, touching base with patients to update them on the status of their appointment—was implemented in the reception areas to better communicate with waiting patients. Medical home staff “huddles” were conducted daily to improve communication and help keep the focus on patients and their families. Postvisit phone calls, made by medical home clinical staff, helped ensure that patients understood and followed care instructions. Staff members were also trained to “acknowledge, apologize [for], and amend” experiences that did not meet the expectations of patients and their families. Finally, capital improvements were made in selected facilities to improve patient experience.
Study Data And Methods A consecutive sample—that is, a sample designed to include all available subjects—was drawn from the electronic medical record. The sample consisted of all patients who had a service recorded in one of the seven patient-centered medical homes during October 2010 and who had had a first or second diagnosis of one or more of three chronic diseases: diabetes, asthma, and congestive heart failure. The formal community health needs assessment conducted by NewYorkPresbyterian had identified these three conditions as being prevalent in Washington Heights– Inwood, of concern to the community, and amenable to care improvement strategies.2,7 Initially 5,963 patients were identified as meeting these criteria. The 111 patients who left the medical home practices or were lost to follow-up during the study period were excluded from our analysis, and we did not study these patients’ subsequent health status and health care history. Therefore, our results are based on the 5,852 patients who remained in the medical home practices throughout the three years of the study. Of these patients, 62.4 percent were female. The mean age was 54.4 years. A pre- and post-intervention design—with the implementation of the NewYork-Presbyterian Regional Health Collaborative constituting the intervention—was used to collect data on the 5,852 patients for one year before October 4, 2010, and for three years after that date. Utilization data were extracted from the hospital’s electronic medical records. The data included ED visits and hospital admissions with a first or second diagnosis of diabetes, asthma, congestive heart failure, or some combination of the three. These data allowed us to calculate average 1988
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The medical homes are linked to community collaborators who have programs to help reduce hospital admissions.
length-of-stay and thirty-day readmissions for patients in the cohort who had hospital admissions. Data on ED use and hospital admissions were collected into a database for longitudinal examination over the four-year study period (one year before and three years after the intervention). The outcomes of interest were the associations between enrollment in one of the medical homes, on the one hand, and ED visits, hospital admissions, average length-of-stay, and thirtyday readmissions, on the other hand. A paired samples t-test was applied to measure the mean variance in the patients’ ED visits and hospital admissions between the pre and post periods, using a two-sided p value with statistical significance determined by an alpha value of less than 0.05. Analysis was conducted using SPSS software, version 19.0. The study was approved by the Institutional Review Board of Columbia University. Patients’ experiences at the medical homes before and after the intervention were captured through the use of Press Ganey patient satisfaction surveys, which NewYork-Presbyterian mailed to randomly selected patients shortly after they visited one of the medical homes. Press Ganey is a third party that is contracted by health care organizations to help measure and improve patient experience. The standardized survey tool, which is written in English and Spanish, includes twenty-eight individual measures in seven areas. The seven areas are overall satisfaction, overall assessment, access, moving through your visit, nursing, care provider, and personal issues.12 The annual survey results were analyzed for one year before the intervention (the baseline) and for three years after it. These data represent aggregate results for all the medical homes in these years. Because survey respondents were
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anonymous, we studied responses linked to all users of the medical homes, not just those linked to patients included in the October 2010 cohort (for patient satisfaction results during the study period, see Appendix Exhibit A3).8
Exhibit 2 Use Of The Emergency Department By 5,852 Patients Of The NewYork-Presbyterian Regional Health Collaborative, 2009–13
Study Results Use Of The Emergency Department The 5,852 patients in our study had a mean of 1.10 ED visits per patient per year in the baseline year (standard deviation: 1.898; 95% confidence interval: 1.05, 1.15). In the third year after the intervention, use of the ED decreased to a mean of 0.77 visits per patient per year (SD: 1.479; 95% CI: 0.73, 0.81). During the three years after the intervention, the study population’s use of the ED decreased by 22.9 percent (p < 0:001; Exhibit 2). The reduction over the four-year period, from baseline to three years after the intervention, was 29.7 percent (p < 0:001). Hospital Admissions At baseline the study population had a mean of 0.50 hospital admissions per patient per year (SD: 1.153; 95% CI: 0.47 0.53). Three years after the intervention, the mean was 0.35 admissions per patient per year (SD: 0.959; 95% CI: 0.33, 0.38). The analysis of hospital admissions for the three-year period found a reduction of 24.4 percent (p < 0:001). The reduction during the four-year period was 28.5 percent (p < 0:001; Exhibit 3). Disease-Specific ED Use And Admissions Patients with one or more of the three selected chronic conditions had significantly fewer visits to the ED and hospital admissions during the three-year post-intervention period. For patients with diabetes, ED visits declined by 29.6 percent (p < 0:001) and hospital admissions by 27.5 percent (p ¼ 0:001). For patients with asthma, ED visits declined by 34.6 percent and hospital admissions by 35.7 percent (p < 0:001 for both). And for patients with congestive heart failure, ED visits declined by 50.8 percent and hospital admissions by 51 percent (p < 0:001 for both). Thirty-Day Readmissions In the baseline period, the study population had 493 readmissions to the hospital within thirty days after a discharge. During the first year after the intervention, there were 479 such readmissions; there were 312 in the third year after the intervention. In the four-year period, the number of thirtyday readmissions declined by 36.7 percent (p < 0:001). Average Length-of-Stay Patients’ average length-of-stay in the hospital was 5.9 days in the baseline period. This fell to 5.7 days for the first year after the intervention and to 5.6 days in the third year. The reduction in the four-year period was 4.9 percent (p < 0:001).
SOURCE Authors’ analysis of data from the NewYork-Presbyterian Hospital Disease Registry. NOTE “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model).
Return On Investment NewYork-Presbyterian estimated that it realized a short-term return on investment13 of $1.11 for each dollar spent on enhanced infrastructure, measures to increase access, and the provision of new services such as care coordination and management. Incremental direct costs of approximately $0.85 million were incurred for the development of the various information systems tools, such as disease registries, dashboards, and call centers to improve access. An additional $1.2 million was spent on targeted care services, provided mainly Exhibit 3 Hospital Admissions Of 5,852 Patients Of The NewYork-Presbyterian Regional Health Collaborative, 2009–13
SOURCE Authors’ analysis of data from the NewYork-Presbyterian Hospital Disease Registry. NOTE “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model).
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Collaborating For Community Health by care managers, for high-risk patients and those with complex conditions. Other indirect costs of $0.919 million included additional language interpretation services, training, data analytics, and organizational overhead. The total gains from this program were $3.281 million. These revenues included approximately $2.9 million annually from the New York State Medicaid program in increased reimbursement rates to the patient-centered medical homes and from ED cost savings of approximately $381,000. The latter amount represented the marginal expense of each avoided ED visit. Longer-term return of investment will be measured by cost savings resulting from the prevention of, or the reduction or delay in, complications associated with chronic disease. In the case of patients with diabetes, these include renal failure, amputation, blindness, stroke, and other debilitating conditions. Patient Experience Each of the twenty-eight Press Ganey measures and mean scores in all seven areas increased from baseline to the third year after the intervention. The mean overall increase was 2.25, on a scale of 0 to 100, and the increase in the twenty-eight measures was 0.8–5.2. The mean score for overall satisfaction rose by 2.0, and that for overall assessment by 2.7 (Exhibit 4). The other mean scores also increased: access by 3.4, moving through your visit by 3.2, nursing by 2.5, care provider by 1.3, and personal issues by 2.3. As noted above, all of the medical homes had participated in the hospital’s We Put Patients First initiative. All homes exhibited similar improvement trends (Appendix Exhibit A3).8
Exhibit 4 Trends In Satisfaction With Patient-Centered Medical Homes In The NewYork-Presbyterian Regional Health Collaborative, 2009–13
SOURCE Authors’ analysis of patient satisfaction data from the Press Ganey Medical Practice Survey (see Note 12 in text). NOTES “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model). The figure shows trends in patients’ scores in the seven areas of the survey, on a scale of 0 to 100.
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Discussion These results provide encouraging evidence that the NewYork-Presbyterian Regional Health Collaborative, which centered on medical homes that were linked through enhanced information systems and collaborative relationships instead of by central governance, can provide cost-effective safety-net care for a largely Hispanic patient population that included people with serious chronic illnesses. The collaborative’s success has important implications for academic medical centers and other institutions that are attempting to improve care delivery for costly safety-net populations across a number of providers and organizations in the absence of central governance. The findings regarding the impact of the collaborative’s medical homes on high-cost chronic conditions are in line with other results reported in the literature. For example, a variety of evaluation designs carried out in different medical home practices have produced reductions in ED visits and hospital admissions for a general adult primary care population and for populations of patients who have chronic conditions, are older than sixty-five, or both.14–18 An exception is a study of the Pennsylvania Chronic Care Initiative that compared use and quality results over three years for thirty-two patient-centered medical homes and twentynine control practices that volunteered to participate in the study, and that found no significant changes in the use of the ED or inpatient services.19 An accompanying editorial by Thomas Schwenk pointed out that volunteerism introduced a number of potential confounders.20 The Group Health medical home pilot also demonstrated improvements in patient satisfaction at year 2.21 Group Health’s reduction in ED visits closely matched our own, but its hospitalization reduction was smaller than ours. We found no comparable data for reductions in thirty-day readmissions or average lengths-ofstay in our literature review. Patient experience measures improved overall in all six medical homes from baseline to three years after the intervention. We believe that the patient-centered medical homes and other partners in the NewYork-Presbyterian Regional Health Collaborative benefited from participating in the concentrated efforts to improve patient satisfaction. NewYork-Presbyterian’s We Put Patients First initiative fit very well with the medical homes’ conversion to team-based care, introduction of care management and enhanced educational services, and greater involvement of front-line staff in the care process. The previsit planning activities also improved patients’ experiences by
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Future studies could help determine the precise effects of multiple interrelated and coordinated interventions.
streamlining visits through minimizing—and, where possible, eliminating—multiple steps in the care process. In contrast to the second and third years after the intervention, in the first post-intervention year there were lower patient satisfaction scores for most measures. This could in part reflect the major changes in scheduling and registration processes that took place during that first year. The early return-on-investment results are also encouraging. Two components were largely responsible for the gains. One was the marginal savings from reductions in the ED losses that occurred because the cost of ED visits exceeded the Medicaid reimbursement. The second was the incremental New York State revenue associated with increased reimbursement rates for Medicaid insured clinic visits as a result of the medical home designation. These incremental revenues would not have been available to the hospital otherwise. The cost of investment included direct staff who managed the medical homes and IT expenses to develop and maintain databases for the medical homes (such as registries and dashboards). The return on investment of 1.11 depended on the increased reimbursement provided by New York State. However, it suggests that adequate reimbursement—together with savings from decreased use—can offset the costs of the additional personnel, IT, and other infrastructure needed to serve populations similar to those in the Washington Heights–Inwood neighborhood. NewYork-Presbyterian is planning to develop an accountable care organization. The significant reductions noted in this study in ED visits and hospital admissions could serve to further improve the hospital’s bottom line by reducing the overall cost of care. Schwenk’s editorial stated that “it is necessary to better understand which features and combination of features of the PCMH [patient-centered
medical home] are most effective for which populations and in what settings.”20(p803) We concur that such an analysis would be useful. However, our study was not designed to ferret out the impact of each intervention on the three diseases that we studied. Nonetheless, in building the model, we were guided wherever possible by interventions that appeared as best practices in the literature and those that had been proven effective in practice. For example, community health workers, shown in the literature to support the provision of culturally competent care, were also found to help reduce asthma-related ED visits in a separate study of our community health worker initiatives.10 The diabetes self-management program was evaluated on an ongoing basis using criteria and standards set by the American Association of Diabetes Educators, and it continually demonstrated improvements in all prescribed clinical parameters.22 The analysis of the subset of medical home patients who received enhanced care management through the Targeted Care Initiative showed substantial reductions in hospitalizations: a decrease of 62.3 percent, compared to 28.5 percent for the overall study population. As part of an academic medical center, the patient-centered medical homes are closely linked to the hospital’s quality improvement activities, which can also benefit the homes’ patients. As an example, one of NewYorkPresbyterian’s three facilities in Washington Heights–Inwood has a nurse care coordinator who provides support after discharge to patients with congestive heart failure. The study population included 369 patients with congestive heart failure, and 92 of them were discharged from the facility. And as part of the collaborative, the medical homes are linked to community collaborators who have programs to help reduce hospital admissions. Examples include the coordinated home care efforts of the Visiting Nurse Services of New York and the Together on Diabetes program that supports seniors in the community who have diabetes. All of these factors could be contributing to the improved results achieved by the collaborative. Future studies could help determine the precise effects of the multiple interrelated and coordinated interventions.
Conclusion The NewYork-Presbyterian Regional Health Collaborative continues to develop and innovate on behalf of its patients and their families as it grows into a “medical village”—a geographically N ov e m b e r 201 4
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Collaborating For Community Health defined community with a number of patientcentered medical homes that are linked to other providers and community-based resources.7 We expect that ongoing workforce transformations, such as the expansion of patient navigator programs within medical home teams—together with the growing service collaborations and information systems linkages and the increasing The authors gratefully acknowledge Roger D. Vaughan, Mailman School of Public Health, Columbia University, for
sophistication of risk identification and care management processes—will help deliver the full promise of the model: improved care, improved outcomes, improved health, an enhanced patient experience, and lower overall costs through higher quality and more efficient, appropriate, and effective care. ▪
his assistance in reviewing the article’s methodology and Hanna Gungor, Ambulatory Care Operations, NewYork-
Presbyterian, for her contributions to the patient experience sections.
NOTES 1 Carrillo JE, Carrillo V, Perez H, Salas-Lopez D, Natale-Pereira A, Bryon AT. Defining and targeting health care access barriers. J Health Care Poor Underserved. 2011;22(2): 562–75. 2 Aguirre-Molina M. Community needs assessment for Washington Heights–Inwood. New York (NY): Columbia University, Mailman School of Public Health, Department of Population and Family Health; 2006. Unpublished report for NewYork-Presbyterian Hospital. 3 Census Bureau. Socioeconomic profile social characteristics—New York City: 1990 and 2000 census [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http://www.nyc.gov/html/ dcp/pdf/census/socionyc.pdf 4 Census Bureau. Socioeconomic profile social characteristics— Manhattan Community District 12: 1990 and 2000 census [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http://www.nyc.gov/html/dcp/pdf/ census/1990-2000_mn_cd_profile .pdf 5 Census Bureau. American FactFinder: ACS demographic and housing estimates [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http:// factfinder2.census.gov/faces/table services/jsf/pages/productview .xhtml?pid=ACS_10_1YR_DP05 &prodType=table 6 Kaplan S. 2009 Ambulatory care network annual quality and safety report. New York (NY): NewYorkPresbyterian Hospital Ambulatory Care Network; 2010. 7 Carrillo JE, Shekhani NS, Deland EL, Fleck EM, Mucaria J, Guimento R,
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et al. A regional health collaborative formed by NewYork-Presbyterian aims to improve the health of a largely Hispanic community. Health Aff (Millwood). 2011;30(10): 1955–64. To access the Appendix, click on the Appendix link in the box to the right of the article online. Singh P, Chokshi DA. Community health workers—a local solution to a global problem. N Engl J Med. 2013; 369(10):894–6. Peretz PJ, Matiz LA, Findley S, Lizardo M, Evans D, McCord M. Community health workers as drivers of a successful community-based disease management initiative. Am J Public Health. 2012;102(8):1443–6. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130(10):829–34. For details about the Press Ganey Medical Practice Survey, see Agency for Healthcare Research and Quality. National quality measures clearing house: measure summary [Internet]. Rockville (MD): AHRQ; [cited 2014 Sep 29]. Available from: http:// www.qualitymeasures.ahrq.gov/ content.aspx?id=34425 The return on investment was calculated as (gain from investment− cost of investment) / (cost of investment). Alexander JA, Bae D. Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes. Health Serv Manage Res. 2012;25(2):51–9. Hoff T, Weller W, DePuccio M. The patient-centered medical home: a review of recent research. Med Care Res Rev. 2012;69(6):619–44.
16 Counsell SR, Callahan CM, Clark DO, Tu W, Bultar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007; 298(22):2623–33. 17 McCarthy D, Nuzum R, Mika S, Wrenn J, Wakefield M. The North Dakota experience: achieving highperformance health care through rural innovation and cooperation. New York (NY): Commonwealth Fund; 2008. (Publication No. 1130). 18 Harbrecht MG, Latts LM. Colorado’s Patient-Centered Medical Home Pilot met numerous obstacles, yet saw results such as reduced hospital admissions. Health Aff (Millwood). 2012;31(9):2010–7. 19 Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815–25. 20 Schwenk TL. The patientcentered medical home: one size does not fit all. JAMA. 2014;311(8): 802–3. 21 Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835–43. 22 Varghese L, Cabral Y. Implementing the Diabetes Self-Management Education Program (DSME) in a patientcentered medical home: an evidencebased model of care. Abstract presented at: annual conference of the American Association of Diabetes Educators, 2014 Aug 8, Orlando, FL.
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Collaborating For Community Health By J. Emilio Carrillo, Victor A. Carrillo, Robert Guimento, Jaclyn Mucaria, and Joan Leiman 10.1377/hlthaff.2014.0408 HEALTH AFFAIRS 33, NO. 11 (2014): 1985–1992 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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The NewYork-Presbyterian Regional Health Collaborative: A Three-Year Progress Report
J. Emilio Carrillo is vice president of community health, NewYork-Presbyterian Hospital, in New York City.
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
D
isadvantaged communities, whose residents face numerous social and cultural barriers, often experience gaps in health care. They also pose significant challenges to the academic medical centers that provide care to the residents of these communities because the financial, cognitive, and structural barriers that residents face often lead to decreased screening rates, delayed care seeking, and lack of treatment.1 The Washington Heights–Inwood community, located at the northern tip of Manhattan, is a disadvantaged community. Most of its residents
Victor A. Carrillo (vac9009@ nyp.org) is director of community health development at NewYorkPresbyterian Hospital. Robert Guimento is vice president of ambulatory care at NewYork-Presbyterian Hospital. Jaclyn Mucaria is senior vice president of ambulatory care and patient-centered services at NewYork-Presbyterian Hospital. Joan Leiman is a special lecturer in health policy and management and in international and public affairs at the Mailman School of Public Health, Columbia University, in New York City.
are Spanish-speaking immigrants, and nearly one-fourth have incomes below the federal poverty level (Exhibit 1). They face socioeconomic and health disparities compared to the rest of New York City.2–4 More than 60 percent of the community’s estimated 205,000 residents receive their care from NewYork-Presbyterian Hospital, and more than 40 percent do so through the hospital’s ambulatory practices.5,6 In 2008, recognizing that the health needs of this predominantly low-income and Hispanic population were going unmet, NewYorkPresbyterian embarked on a population health initiative. After conducting a formal health November 2014
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H ea lt h A f fai r s
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Collaborating For Community Health Exhibit 1 Demographic Characteristics Of Washington Heights–Inwood And New York City, 2010–12 Characteristic Race or ethnicitya Hispanic White non-Hispanic African American non-Hispanic Asian or Pacific Islander
Washington Heights–Inwood
New York City
71.0% 17.6 7.3 2.5
28.6% 33.3 25.5 12.7
48.9 67.9 19.9
37.3 24.7 10.5
$39,535 15.6% 23.6
$50,711 11% 20.8
Literacy and education Born outside the US Speaks Spanish at home Less than 9th grade education
gan October 4, 2010. Data for the first six-month period on a cohort of nearly six thousand patients who enrolled in October 2010 were promising. The data demonstrated a significant 9.2 percent decline in emergency department (ED) visits for conditions that could be treated on an ambulatory basis and a 5.8 percent decrease in hospitalizations, which was not significant).7 This article reports on the outcomes of the same cohort of patients three years after implementation (see online Appendix Exhibits A1 and A2 for patients’ demographic characteristics and chronic disease distribution, respectively).8
Economic status Median household income Unemployment rate Percent of population below poverty level
SOURCE Authors’ analysis of data from the New York City Department of Health and Mental Hygiene. a Percentages do not sum to 100 because of “other” or “unspecified” responses.
needs assessment of the community and reviewing the services the hospital offered residents, NewYork-Presbyterian joined forces with the physicians and schools of the Columbia University Medical Center and with community-based providers and organizations to reinvent its ambulatory health care delivery model. The goal was to reduce health disparities at both the individual and population levels.1,2 In October 2010 the NewYork-Presbyterian Regional Health Collaborative was launched. It was a rational, coordinated system of care delivery that was intended to measurably improve the health of the Washington Heights–Inwood population. Unlike integrated delivery systems such as Kaiser Permanente Southern California, which operate under central governance, the NewYorkPresbyterian Regional Health Collaborative consists of independent entities. The collaborative contains a hospital and a university faculty practice, which—together with community physicians, home care agencies, community-based organizations, and other schools in Columbia University—share the goal of measurably improving the health of the community. Evidence-based strategies, information technology (IT), and cultural competency are used to reorganize care delivery around the needs of patients and families. NewYork-Presbyterian developed care protocols and information systems and conducted extensive training for physicians, nurses, and other care team members in June and July 2010, before piloting the model starting in August 2010. Full implementation of the collaborative be1986
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The Care Model The centerpiece of the NewYork-Presbyterian Regional Health Collaborative was the conversion of seven ambulatory care centers in the community into patient-centered medical homes. All seven have received level 3 certification (the highest level available) from the National Committee for Quality Assurance. Since our initial report,8 two medical homes have merged their services into one facility, leaving a total of six. The Community Health Team The medical homes provide care through interdisciplinary community health teams that are led by primary care physicians and that include nurse care managers, primary care nurses, nurse practitioners, nurse disease managers, social workers, nutritionists, and pharmacists. Also part of the team are members of a new generation of culturally competent front-line workers from the community who are bilingual and whose cultural backgrounds are similar to those of the community residents served by the practice. These front-line workers include medical assistants, patient registrars, and community health workers. In many other settings, community health workers are adjuncts to the care team and are not directly embedded in its day-to-day functions. However, the NewYork-Presbyterian Regional Health Collaborative’s community health workers are subcontracted from collaborating community-based organizations and are integrated into interdisciplinary community health teams.9,10 Care roles and responsibilities were realigned for team care delivery, and front-line workers participate in weekly interdisciplinary community health team meetings and daily previsit conferences (“huddles”) as needed. They also receive training in care processes and the use of information systems tools. Hospital residents in internal medicine, pediatrics, and family medicine participate in the care teams. Residents are trained in care coordination, transitions of care and care continuity,
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Patient-family advisory councils were created to provide channels to identify areas of importance to improve patient satisfaction and care.
and patient-based cross-cultural communication.11 The weekly interdisciplinary community health team meetings have about twelve participants and last one hour. The meetings are chaired by a primary care physician and are facilitated by a nurse care manager, who searches the hospital’s electronic disease registries to identify high-risk patients who have a high number of ED visits, hospital admissions, or both or who have abnormal clinical indicators for one or more chronic conditions. The team discusses these at-risk patients and formulates plans for reaching out to them and caring for them. Each day a subset of the team conducts “previsit planning” to help prepare for patients’ visits by anticipating what screenings, referrals, and educational activities will be necessary. This helps improve the efficiency and effectiveness of the visit. The electronic registries and patient care dashboards—components of the electronic medical record that summarize the patient’s chronic conditions, laboratory results, and required tests and screenings—provide the necessary data. Nurse disease managers help educate patients with diabetes about managing their condition. In late 2011 the medical homes implemented a Diabetes Self-Management Education Program that was based on a standardized curriculum endorsed by the American Association of Diabetes Educators. Additionally, a community-based program called Together on Diabetes—a collaboration involving a number of agencies—supports and educates seniors with diabetes who reside in Washington Heights–Inwood. Care Management Of High-Risk Patients With Complex Conditions To better manage high-risk patients who have multiple comorbidities and face a number of sociocultural challenges, a medical home–based Targeted Care
Initiative was implemented in July 2011. In this initiative, electronic disease registries are used to identify patients with a diagnosis of diabetes, congestive heart failure, asthma, or some combination of the three who have had high use of NewYork-Presbyterian during the preceding twelve months—that is, on at least three occasions they have either visited the ED or been admitted to the hospital. Nurse care managers review the patients’ records to assess the potential impact of care management services on the patients’ care. In addition, the medical home primary care providers refer patients with complex conditions who are not following their care plans to the care management program for further assessment and intervention by the nurse care managers. These managers are embedded in the interdisciplinary community health team and are supported by a specialized subteam of care management assistants, pharmacists, psychiatric social workers, and community health workers. Protocols have been established to provide the highest-risk patients with close care management, to follow them with less intensity as they improve, and to resume more intensive support if they falter. The highest-risk patients are closely tracked and are offered additional support by community health workers, who provide outreach and education in the community as well as in the patient’s home. Improving The Patient Experience The medical homes became an integral part of NewYork-Presbyterian’s efforts to promote patient-centered care and improve patient experience. Each medical home also participated in the hospital’s We Put Patients First initiative, a program that was launched in 2007 to deliver the best clinical care, focusing on every interaction with a patient and adhering to the highest standards of quality and patient safety. The medical homes adapted elements of the initiative and made them part of the homes’ team processes and patient education activities. Interdisciplinary community health teams also developed Making It Better Plans. These served as year-long road maps to help the medical homes achieve specific goals, such as improving communication when greeting a patient and promoting the smoother flow of patients through their visits to minimize wait times. Patient-family advisory councils were created to provide channels for patients and their families to identify areas of importance to improve patient satisfaction and care. Patient-centered care committees were established at each medical home and held regular meetings to share data and information. The committees also set goals and targets to institutionalize best practices; N ov em b e r 2 0 1 4
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Collaborating For Community Health promote employee recognition; and improve teamwork, communication, and respect for the patient. “Patient rounding”—that is, touching base with patients to update them on the status of their appointment—was implemented in the reception areas to better communicate with waiting patients. Medical home staff “huddles” were conducted daily to improve communication and help keep the focus on patients and their families. Postvisit phone calls, made by medical home clinical staff, helped ensure that patients understood and followed care instructions. Staff members were also trained to “acknowledge, apologize [for], and amend” experiences that did not meet the expectations of patients and their families. Finally, capital improvements were made in selected facilities to improve patient experience.
Study Data And Methods A consecutive sample—that is, a sample designed to include all available subjects—was drawn from the electronic medical record. The sample consisted of all patients who had a service recorded in one of the seven patient-centered medical homes during October 2010 and who had had a first or second diagnosis of one or more of three chronic diseases: diabetes, asthma, and congestive heart failure. The formal community health needs assessment conducted by NewYorkPresbyterian had identified these three conditions as being prevalent in Washington Heights– Inwood, of concern to the community, and amenable to care improvement strategies.2,7 Initially 5,963 patients were identified as meeting these criteria. The 111 patients who left the medical home practices or were lost to follow-up during the study period were excluded from our analysis, and we did not study these patients’ subsequent health status and health care history. Therefore, our results are based on the 5,852 patients who remained in the medical home practices throughout the three years of the study. Of these patients, 62.4 percent were female. The mean age was 54.4 years. A pre- and post-intervention design—with the implementation of the NewYork-Presbyterian Regional Health Collaborative constituting the intervention—was used to collect data on the 5,852 patients for one year before October 4, 2010, and for three years after that date. Utilization data were extracted from the hospital’s electronic medical records. The data included ED visits and hospital admissions with a first or second diagnosis of diabetes, asthma, congestive heart failure, or some combination of the three. These data allowed us to calculate average 1988
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The medical homes are linked to community collaborators who have programs to help reduce hospital admissions.
length-of-stay and thirty-day readmissions for patients in the cohort who had hospital admissions. Data on ED use and hospital admissions were collected into a database for longitudinal examination over the four-year study period (one year before and three years after the intervention). The outcomes of interest were the associations between enrollment in one of the medical homes, on the one hand, and ED visits, hospital admissions, average length-of-stay, and thirtyday readmissions, on the other hand. A paired samples t-test was applied to measure the mean variance in the patients’ ED visits and hospital admissions between the pre and post periods, using a two-sided p value with statistical significance determined by an alpha value of less than 0.05. Analysis was conducted using SPSS software, version 19.0. The study was approved by the Institutional Review Board of Columbia University. Patients’ experiences at the medical homes before and after the intervention were captured through the use of Press Ganey patient satisfaction surveys, which NewYork-Presbyterian mailed to randomly selected patients shortly after they visited one of the medical homes. Press Ganey is a third party that is contracted by health care organizations to help measure and improve patient experience. The standardized survey tool, which is written in English and Spanish, includes twenty-eight individual measures in seven areas. The seven areas are overall satisfaction, overall assessment, access, moving through your visit, nursing, care provider, and personal issues.12 The annual survey results were analyzed for one year before the intervention (the baseline) and for three years after it. These data represent aggregate results for all the medical homes in these years. Because survey respondents were
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anonymous, we studied responses linked to all users of the medical homes, not just those linked to patients included in the October 2010 cohort (for patient satisfaction results during the study period, see Appendix Exhibit A3).8
Exhibit 2 Use Of The Emergency Department By 5,852 Patients Of The NewYork-Presbyterian Regional Health Collaborative, 2009–13
Study Results Use Of The Emergency Department The 5,852 patients in our study had a mean of 1.10 ED visits per patient per year in the baseline year (standard deviation: 1.898; 95% confidence interval: 1.05, 1.15). In the third year after the intervention, use of the ED decreased to a mean of 0.77 visits per patient per year (SD: 1.479; 95% CI: 0.73, 0.81). During the three years after the intervention, the study population’s use of the ED decreased by 22.9 percent (p < 0:001; Exhibit 2). The reduction over the four-year period, from baseline to three years after the intervention, was 29.7 percent (p < 0:001). Hospital Admissions At baseline the study population had a mean of 0.50 hospital admissions per patient per year (SD: 1.153; 95% CI: 0.47 0.53). Three years after the intervention, the mean was 0.35 admissions per patient per year (SD: 0.959; 95% CI: 0.33, 0.38). The analysis of hospital admissions for the three-year period found a reduction of 24.4 percent (p < 0:001). The reduction during the four-year period was 28.5 percent (p < 0:001; Exhibit 3). Disease-Specific ED Use And Admissions Patients with one or more of the three selected chronic conditions had significantly fewer visits to the ED and hospital admissions during the three-year post-intervention period. For patients with diabetes, ED visits declined by 29.6 percent (p < 0:001) and hospital admissions by 27.5 percent (p ¼ 0:001). For patients with asthma, ED visits declined by 34.6 percent and hospital admissions by 35.7 percent (p < 0:001 for both). And for patients with congestive heart failure, ED visits declined by 50.8 percent and hospital admissions by 51 percent (p < 0:001 for both). Thirty-Day Readmissions In the baseline period, the study population had 493 readmissions to the hospital within thirty days after a discharge. During the first year after the intervention, there were 479 such readmissions; there were 312 in the third year after the intervention. In the four-year period, the number of thirtyday readmissions declined by 36.7 percent (p < 0:001). Average Length-of-Stay Patients’ average length-of-stay in the hospital was 5.9 days in the baseline period. This fell to 5.7 days for the first year after the intervention and to 5.6 days in the third year. The reduction in the four-year period was 4.9 percent (p < 0:001).
SOURCE Authors’ analysis of data from the NewYork-Presbyterian Hospital Disease Registry. NOTE “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model).
Return On Investment NewYork-Presbyterian estimated that it realized a short-term return on investment13 of $1.11 for each dollar spent on enhanced infrastructure, measures to increase access, and the provision of new services such as care coordination and management. Incremental direct costs of approximately $0.85 million were incurred for the development of the various information systems tools, such as disease registries, dashboards, and call centers to improve access. An additional $1.2 million was spent on targeted care services, provided mainly Exhibit 3 Hospital Admissions Of 5,852 Patients Of The NewYork-Presbyterian Regional Health Collaborative, 2009–13
SOURCE Authors’ analysis of data from the NewYork-Presbyterian Hospital Disease Registry. NOTE “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model).
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Collaborating For Community Health by care managers, for high-risk patients and those with complex conditions. Other indirect costs of $0.919 million included additional language interpretation services, training, data analytics, and organizational overhead. The total gains from this program were $3.281 million. These revenues included approximately $2.9 million annually from the New York State Medicaid program in increased reimbursement rates to the patient-centered medical homes and from ED cost savings of approximately $381,000. The latter amount represented the marginal expense of each avoided ED visit. Longer-term return of investment will be measured by cost savings resulting from the prevention of, or the reduction or delay in, complications associated with chronic disease. In the case of patients with diabetes, these include renal failure, amputation, blindness, stroke, and other debilitating conditions. Patient Experience Each of the twenty-eight Press Ganey measures and mean scores in all seven areas increased from baseline to the third year after the intervention. The mean overall increase was 2.25, on a scale of 0 to 100, and the increase in the twenty-eight measures was 0.8–5.2. The mean score for overall satisfaction rose by 2.0, and that for overall assessment by 2.7 (Exhibit 4). The other mean scores also increased: access by 3.4, moving through your visit by 3.2, nursing by 2.5, care provider by 1.3, and personal issues by 2.3. As noted above, all of the medical homes had participated in the hospital’s We Put Patients First initiative. All homes exhibited similar improvement trends (Appendix Exhibit A3).8
Exhibit 4 Trends In Satisfaction With Patient-Centered Medical Homes In The NewYork-Presbyterian Regional Health Collaborative, 2009–13
SOURCE Authors’ analysis of patient satisfaction data from the Press Ganey Medical Practice Survey (see Note 12 in text). NOTES “Baseline” is one year before October 2010, the date of the intervention (implementation of the patient-centered medical home model). The figure shows trends in patients’ scores in the seven areas of the survey, on a scale of 0 to 100.
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Discussion These results provide encouraging evidence that the NewYork-Presbyterian Regional Health Collaborative, which centered on medical homes that were linked through enhanced information systems and collaborative relationships instead of by central governance, can provide cost-effective safety-net care for a largely Hispanic patient population that included people with serious chronic illnesses. The collaborative’s success has important implications for academic medical centers and other institutions that are attempting to improve care delivery for costly safety-net populations across a number of providers and organizations in the absence of central governance. The findings regarding the impact of the collaborative’s medical homes on high-cost chronic conditions are in line with other results reported in the literature. For example, a variety of evaluation designs carried out in different medical home practices have produced reductions in ED visits and hospital admissions for a general adult primary care population and for populations of patients who have chronic conditions, are older than sixty-five, or both.14–18 An exception is a study of the Pennsylvania Chronic Care Initiative that compared use and quality results over three years for thirty-two patient-centered medical homes and twentynine control practices that volunteered to participate in the study, and that found no significant changes in the use of the ED or inpatient services.19 An accompanying editorial by Thomas Schwenk pointed out that volunteerism introduced a number of potential confounders.20 The Group Health medical home pilot also demonstrated improvements in patient satisfaction at year 2.21 Group Health’s reduction in ED visits closely matched our own, but its hospitalization reduction was smaller than ours. We found no comparable data for reductions in thirty-day readmissions or average lengths-ofstay in our literature review. Patient experience measures improved overall in all six medical homes from baseline to three years after the intervention. We believe that the patient-centered medical homes and other partners in the NewYork-Presbyterian Regional Health Collaborative benefited from participating in the concentrated efforts to improve patient satisfaction. NewYork-Presbyterian’s We Put Patients First initiative fit very well with the medical homes’ conversion to team-based care, introduction of care management and enhanced educational services, and greater involvement of front-line staff in the care process. The previsit planning activities also improved patients’ experiences by
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Future studies could help determine the precise effects of multiple interrelated and coordinated interventions.
streamlining visits through minimizing—and, where possible, eliminating—multiple steps in the care process. In contrast to the second and third years after the intervention, in the first post-intervention year there were lower patient satisfaction scores for most measures. This could in part reflect the major changes in scheduling and registration processes that took place during that first year. The early return-on-investment results are also encouraging. Two components were largely responsible for the gains. One was the marginal savings from reductions in the ED losses that occurred because the cost of ED visits exceeded the Medicaid reimbursement. The second was the incremental New York State revenue associated with increased reimbursement rates for Medicaid insured clinic visits as a result of the medical home designation. These incremental revenues would not have been available to the hospital otherwise. The cost of investment included direct staff who managed the medical homes and IT expenses to develop and maintain databases for the medical homes (such as registries and dashboards). The return on investment of 1.11 depended on the increased reimbursement provided by New York State. However, it suggests that adequate reimbursement—together with savings from decreased use—can offset the costs of the additional personnel, IT, and other infrastructure needed to serve populations similar to those in the Washington Heights–Inwood neighborhood. NewYork-Presbyterian is planning to develop an accountable care organization. The significant reductions noted in this study in ED visits and hospital admissions could serve to further improve the hospital’s bottom line by reducing the overall cost of care. Schwenk’s editorial stated that “it is necessary to better understand which features and combination of features of the PCMH [patient-centered
medical home] are most effective for which populations and in what settings.”20(p803) We concur that such an analysis would be useful. However, our study was not designed to ferret out the impact of each intervention on the three diseases that we studied. Nonetheless, in building the model, we were guided wherever possible by interventions that appeared as best practices in the literature and those that had been proven effective in practice. For example, community health workers, shown in the literature to support the provision of culturally competent care, were also found to help reduce asthma-related ED visits in a separate study of our community health worker initiatives.10 The diabetes self-management program was evaluated on an ongoing basis using criteria and standards set by the American Association of Diabetes Educators, and it continually demonstrated improvements in all prescribed clinical parameters.22 The analysis of the subset of medical home patients who received enhanced care management through the Targeted Care Initiative showed substantial reductions in hospitalizations: a decrease of 62.3 percent, compared to 28.5 percent for the overall study population. As part of an academic medical center, the patient-centered medical homes are closely linked to the hospital’s quality improvement activities, which can also benefit the homes’ patients. As an example, one of NewYorkPresbyterian’s three facilities in Washington Heights–Inwood has a nurse care coordinator who provides support after discharge to patients with congestive heart failure. The study population included 369 patients with congestive heart failure, and 92 of them were discharged from the facility. And as part of the collaborative, the medical homes are linked to community collaborators who have programs to help reduce hospital admissions. Examples include the coordinated home care efforts of the Visiting Nurse Services of New York and the Together on Diabetes program that supports seniors in the community who have diabetes. All of these factors could be contributing to the improved results achieved by the collaborative. Future studies could help determine the precise effects of the multiple interrelated and coordinated interventions.
Conclusion The NewYork-Presbyterian Regional Health Collaborative continues to develop and innovate on behalf of its patients and their families as it grows into a “medical village”—a geographically N ov e m b e r 201 4
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Collaborating For Community Health defined community with a number of patientcentered medical homes that are linked to other providers and community-based resources.7 We expect that ongoing workforce transformations, such as the expansion of patient navigator programs within medical home teams—together with the growing service collaborations and information systems linkages and the increasing The authors gratefully acknowledge Roger D. Vaughan, Mailman School of Public Health, Columbia University, for
sophistication of risk identification and care management processes—will help deliver the full promise of the model: improved care, improved outcomes, improved health, an enhanced patient experience, and lower overall costs through higher quality and more efficient, appropriate, and effective care. ▪
his assistance in reviewing the article’s methodology and Hanna Gungor, Ambulatory Care Operations, NewYork-
Presbyterian, for her contributions to the patient experience sections.
NOTES 1 Carrillo JE, Carrillo V, Perez H, Salas-Lopez D, Natale-Pereira A, Bryon AT. Defining and targeting health care access barriers. J Health Care Poor Underserved. 2011;22(2): 562–75. 2 Aguirre-Molina M. Community needs assessment for Washington Heights–Inwood. New York (NY): Columbia University, Mailman School of Public Health, Department of Population and Family Health; 2006. Unpublished report for NewYork-Presbyterian Hospital. 3 Census Bureau. Socioeconomic profile social characteristics—New York City: 1990 and 2000 census [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http://www.nyc.gov/html/ dcp/pdf/census/socionyc.pdf 4 Census Bureau. Socioeconomic profile social characteristics— Manhattan Community District 12: 1990 and 2000 census [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http://www.nyc.gov/html/dcp/pdf/ census/1990-2000_mn_cd_profile .pdf 5 Census Bureau. American FactFinder: ACS demographic and housing estimates [Internet]. Washington (DC): Census Bureau; [cited 2014 Sep 4]. Available from: http:// factfinder2.census.gov/faces/table services/jsf/pages/productview .xhtml?pid=ACS_10_1YR_DP05 &prodType=table 6 Kaplan S. 2009 Ambulatory care network annual quality and safety report. New York (NY): NewYorkPresbyterian Hospital Ambulatory Care Network; 2010. 7 Carrillo JE, Shekhani NS, Deland EL, Fleck EM, Mucaria J, Guimento R,
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et al. A regional health collaborative formed by NewYork-Presbyterian aims to improve the health of a largely Hispanic community. Health Aff (Millwood). 2011;30(10): 1955–64. To access the Appendix, click on the Appendix link in the box to the right of the article online. Singh P, Chokshi DA. Community health workers—a local solution to a global problem. N Engl J Med. 2013; 369(10):894–6. Peretz PJ, Matiz LA, Findley S, Lizardo M, Evans D, McCord M. Community health workers as drivers of a successful community-based disease management initiative. Am J Public Health. 2012;102(8):1443–6. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130(10):829–34. For details about the Press Ganey Medical Practice Survey, see Agency for Healthcare Research and Quality. National quality measures clearing house: measure summary [Internet]. Rockville (MD): AHRQ; [cited 2014 Sep 29]. Available from: http:// www.qualitymeasures.ahrq.gov/ content.aspx?id=34425 The return on investment was calculated as (gain from investment− cost of investment) / (cost of investment). Alexander JA, Bae D. Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes. Health Serv Manage Res. 2012;25(2):51–9. Hoff T, Weller W, DePuccio M. The patient-centered medical home: a review of recent research. Med Care Res Rev. 2012;69(6):619–44.
16 Counsell SR, Callahan CM, Clark DO, Tu W, Bultar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007; 298(22):2623–33. 17 McCarthy D, Nuzum R, Mika S, Wrenn J, Wakefield M. The North Dakota experience: achieving highperformance health care through rural innovation and cooperation. New York (NY): Commonwealth Fund; 2008. (Publication No. 1130). 18 Harbrecht MG, Latts LM. Colorado’s Patient-Centered Medical Home Pilot met numerous obstacles, yet saw results such as reduced hospital admissions. Health Aff (Millwood). 2012;31(9):2010–7. 19 Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815–25. 20 Schwenk TL. The patientcentered medical home: one size does not fit all. JAMA. 2014;311(8): 802–3. 21 Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835–43. 22 Varghese L, Cabral Y. Implementing the Diabetes Self-Management Education Program (DSME) in a patientcentered medical home: an evidencebased model of care. Abstract presented at: annual conference of the American Association of Diabetes Educators, 2014 Aug 8, Orlando, FL.
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