NewYork-Presbyterian leveraged its resources and the collective impact of the Washington Heights-Inwood community to form a Regional Health Collaborative. The Collaborative is an integrated network of primary care and other healthcare providers, ten school-based clinics, and community-based resources that form a "medical village" serving the health needs of a predominantly poor, Hispanic population.
The effort began by targeting leading health challenges in the community: diabetes, asthma, heart failure, depression, and childhood obesity. A core of seven ambulatory care centers was recruited to work together to attain Patient-Centered Medical Home (PCMH) status, and create Interdisciplinary Care Teams that would address conditions collaboratively with a focus on prevention. Many more chronic physical and behavioral conditions are now addressed through the Collaborative, and their central electronic registry includes 54,000 patients, about a quarter of the community's population.
In 2014, the Collaborative reported a 29.7% reduction in emergency department hospitalizations, and a 28.5% reduction in inpatient hospitalizations among its patients.