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Let’s Hope “Ol’ Blue Eyes” is Prophetic When it Comes to Community Health

November 6, 2014
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The most famous words to any song written about New York City are…”If I can make it there, I’ll make it anywhere.”

Frank Sinatra's famous line: A harbinger for population health management?Over time, Frank Sinatra’s famous line (or should I say Fred Ebb?) has proven to be an accurate assessment of living in this city. It’s not my East Coast arrogance. It’s the cost of living, the high-energy, the fact that you can’t walk down the street without walking past people who are at the top of their field, the culture, the fashion, and just the sheer overwhelming nature of just being here.

It is true. If you can make it here, you can make it anywhere.

But I’m not here to praise New York. I am here to say that I thought of that famous line when I ran across an interesting study in Health Affairs. The study examined the efforts of a medical village, overseen by the New York-Presbyterian Regional Health Collaborative, in improving the health of residents in the Washington Heights-Inwood community in northern Manhattan.

Quite simply, I hope Sinatra’s words become prophetic when it comes to improving the overall health in low-income neighborhoods. If a medical village can make it here, hopefully it can make it anywhere.

The New York-Presbyterian Regional Health Collaborative created a medical village, which they say “goes beyond the established patient-centered medical home mode.” It connects an academic medical center with a large ambulatory network, medical homes, other providers, and community resources all through an IT infrastructure. This includes school-based clinics and specialty-care centers (the ones that are a part of NYP’s network). Basically, it’s using IT to connect everything that interacts with people’s healthcare in this area of Harlem.

In the program, the IT infrastructure works in concert with front-line community health teams. These teams include community health workers embedded in the day-to-day functions of the neighborhood residents. The team, led by providers, meets and formulates plans for at-risk patients. They plan out what screenings, referrals, and educational activities will be necessary for a patient using electronic registries and dashboards. There is also a lot of patient outreach involved in the program.

The medical village project began in 2010. The results have been astounding and encouraging since then. In a study of 5,852 patients with conditions including diabetes, asthma, and congestive heart failure, emergency department visits and hospitalizations were reduced by 29.7 percent and 28.5 percent, respectively. Thirty-day readmission rates dropped by a whopping 36.7 percent. Patient satisfaction, as measured by Press-Ganey, improved in all measures.

We know the uphill climb that low-income communities face with their healthcare and we know the risks they present to high-end medical centers. Having written about care management for an upcoming feature (check HCI online soon!), it’s clear that providers are having trouble defining the true necessities for an effective program, the kind that typically aims to improve health outcomes for those that need the most help. You know, like the people who live in the Washington Heights-Inwood community.

The most encouraging part of the New York-Presbyterian initiative is that those involved with the program say it could serve as a model for other academic medical centers across the country.

With that said, I hope Sinatra and the New York-Presbyterian Regional Health Collaborative are right.

Please feel free to respond in the comment section below or on Twitter by following me at @GabrielSPerna