New York-Presbyterian Hospital

Connection to Moving Health Care Upstream

New York-Presbyterian Hospital (NYP) serves as the anchor organization for the Moving Health Care Upstream team in Manhattan, New York. NYP’s project goal is to better address the psychological and social determinants of health of children age 0-5 living in Central Harlem, New York.

Our Community & Need

Our neighborhood is unique in that there is a strong network of community-based organizations, a nationally ranked hospital and teaching facility, and a history of leveraging both resources to promote community intervention.  Despite these resources, Central Harlem is considered a medically underserved community and has a high percentage of low-income children who are at risk for a variety of psycho-social and environmental stressors. Exposure to toxic stress affects health and social trajectory and too many Central Harlem children exposed to this risk factor are undiagnosed, incorrectly diagnosed, or un-linked to effective services.

Our Solution & Our Community Partners

Our upstream work includes implementing a psycho-social screen during well-child visits, stratifying children according to risk-level, and linking families to bundles of care with risk-appropriate levels of intensity. These bundles of care will be provided seamlessly in collaboration with community agencies in order to: improve communication between different sectors that address issues in early childhood; increase community capacity, improve navigation of services and improve outcomes for families of young children. Training of pediatric residents will be integrated into these initiatives to ensure that future generations of pediatricians will incorporate upstream care into their own practices.  NYP’s MHCU team hopes that screening and intervening for toxic stressors will diminish disparities and improve opportunities and outcomes for children in our community and ultimately for our community itself.

Community partners for our work with MHCU include Northern Manhattan Perinatal Partnership (NMPP), a Maternal and Child Health Life Course Organization that offers over twenty services and programs including comprehensive case management and education for pregnant and parenting women in the Harlem area, and Union Settlement (Union), which serves over 10,000 Harlem residents annually through a variety of programs including education, health, youth development, childcare, and economic development. Children identified as high or moderate risk in child-screening will receive bundled services from these two community partners which include connection to a community health worker, home visits, early head start and day care, and access to parenting programs.  Patient voice will also be represented by a newly developed community health worker role, tasked with engaging families at risk and serving as the cultural broker to assess families’ strengths in order to address their needs. Following a model implemented by NYP’s Center for Community Health Navigation, community health workers will be funded through the grant and hired by our community partner in order to increase community capacity and create a replicable and sustainable model.

For More Information

If you would like more information about the upstream work happening in our community please contact: Andres Nieto at [email protected], Dodi Meyer at [email protected], Evelyn Berger at [email protected], or Katherine D’Onfro at [email protected].