Presenting Authors: Jaimee Davis, MS, Ambulatory Care Network, New York - Presbyterian Hospital.

ABSTRACT

Background: In Washington Heights and Inwood, one in three residents lives below the poverty line and major health concerns include diabetes, asthma, heart failure, depression and childhood obesity.

Objectives: Develop a hospital-community partnership model that will: 1) Connect patients to the health care system and to local community resources; 2) Support innovative patient-centered care initiatives; 3) Advance the community health worker role and workforce; 4) Enhance the knowledge base and inform local practice.

Methods: Bilingual community health workers (CHWs) employed by partner community based organizations (CBOs) support patients and their caregivers to navigate the local health system and provide on-going support, education, home visits, and referrals for social services.

Results: Since 2006, graduates of a pediatric asthma initiative demonstrated a 75% reduction in preventable hospital utilization and, since 2012, 62% of graduates of an adult diabetes initiative improved their Hba1C. To date, graduates of both programs demonstrated an increase to nearly 100% in self-confidence around chronic disease management. In 2011, 8 CHWs became members of health care teams in 6 Patient Centered Medical Homes where they provided culturally sensitive education and support to 7471 patients. In 2016, sub-contract agreements were signed with 14 CBOs that employ community health workers now based in communities across New York City.

Implications: This model bridges gaps in care for patients and their caregivers, builds capacity in the community, and can be easily adapted to meet the unique needs of additional communities.

Authors: Patricia Peretz, MPH; Jaimee Davis, MS; Adriana Matiz, MD, FAAP; Patricia Peretz, MPH; Jaimee Davis, MS; Andres Nieto, MPA; Crystal Cartwright, RN; Carmen Cruz; Erline Ramirez Diaz; and Adriana Matiz, MD.