Recorded presentation

Carlene Duncan, Ambulatory Care, New York-Presbyterian Hospital, 622 West 168th Street, VC 10 Area C Rm. 5, New York, NY 10032, 212-342-1618, ckd9001@nyp.org, Jacqueline Martinez, MPH, Center for Community Health Partnerships, Columbia University, 100 Haven Avenue, Suite 27C, New York, NY 10032, and Beryl Earle, PhD, RN, New York Presbyterian Hospital, 630 West 168th Street, New York, NY 10032.

As part of the Northern Manhattan Community Voices Collaborative, Salud a Su Alcance (SASA), Health Within Your Reach, is a community-based coalition comprised of New York-Presbyterian Hospital, three community health centers, and a multi-service community based organization. The mission of SASA is to develop an integrated healthcare delivery system to improve access for the uninsured in a medically underserved community by linking existing community resources, redesigning the health care delivery system, and identifying cost efficient approaches to improve health outcomes. SASA has successfully integrated Community Health Workers (CHW) into a team of providers for a diabetes management program for patients with high Hemoglobin A1c. Patients are identified through the emergency room reduction program or referred by physicians. Patients are assigned a CHW. The CHW assist patients in identifying and reaching treatment goals, teach patient self management skills, and help patient access medical and social services. CHW update the patient's status and documents any existing barriers. Information, communicated to the PCP in real time, is used to make adjustments for treatment plan at the primary care visit. A case manager serving as the clinical resource for the CHW, provides one-to-one counseling. A Referral Specialist maintains a network of service providers for patients and facilitates appointment scheduling. An impact evaluation has been implemented. Preliminary results indicate a significant increase in treatment compliance and an initial decrease in hemoglobin A1c levels. During the presentation, CHW will demonstrate the model, discuss challenges and successes, illustrate the training required, and review an evaluation design.

Learning Objectives: At the end of the session, participants will be able to

(
• Assess how to effectively integrate Community Health Workers in a larger health care system and achieve tangible results. (
• Discuss a model for training CHWs that are integrated into a healthcare team (
• Apply an evaluation tool that measure Return on Investment from projects that incorporate CHWs. (
• Identify four or more strategies on influencing different players of the healthcare system to recognize the value of CHWs (
• Define at least 3 successful strategies and 3 program challenges

Keywords: Community Health Advisor, Disease Management

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: New York Presbyterian Hospital Alianza Dominicana
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: New York-Presbyterian Hospital--Employer HRSA-Grant

Recorded presentation