Health Affairs · 2011 · 14 citations · 6 references
Public HealthCommunity HealthUrban HealthHealth EquityIntegrated CarePrimary CareCommunity Health ImprovementCommunity Health Information SystemsCommunity Health SystemsCommunity-based CarePrimary Health CareUrban Health SystemsAmbulatory Care OrganizationCommunity-based ResourcesCultural CompetenceHealth Priority SettingImmigrant Health Care AccessImmigrant Health DisparitiesLatino Health DisparitiesLimited English Proficiency Access
Communities of poor, low-income immigrants with limited English proficiency and disproportionate health burdens pose unique challenges to health providers and policy makers. NewYork-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. NewYork-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.
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The Care Transitions Intervention
Eric A. Coleman, Carla Parry, Sandra Chalmers et al. · Archives of Internal Medicine · 2006 · 1.9K citations
Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders
Mary D. Naylor, Dorothy Brooten, Roberta Campbell et al. · JAMA · 1999 · 1.8K citations