Maimonides Medical Center Community Health Needs … CHNA-CSP... · 2016-12-30 · Maimonides...

Maimonides Medical Center

Community Health Needs Assessment and

Community Service Plan 2016-2018

As Adopted and Submitted to the New York State Department of Health December 30, 2016

Service Area Covered

Primary and Secondary Service Areas of Maimonides Medical Center

Participating Hospitals

Maimonides Medical Center

Contact Adam Stolz VP & Chief of Staff [email protected] 718-283-7699

mailto:[email protected]

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Contents

Section Page Federal CHNA

NY CSP

Cover Page X

Foreword 2

Executive Summary 3 X

1 Maimonides Medical Center (MMC) and its Community

About MMC 5

MMC’s Community: Definition and Characteristics 5 X X

MMC’s Engagement with its Community 8

Community Care of Brooklyn (CCB): Overview and Alignment with MMC’s Community Health Program

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2 Identification of Health Needs

Quantitative Component: Health Indicators 10 X X

Qualitative Component: Public Deliberations 19 X X

Qualitative Component: Interviews 22 X X

Qualitative Component: NYS DOHMH TCNY Community Consultations 23 X X

3 Prioritization of Community Health Needs

Selected New York State Prevention Agenda Priorities 24 X X

Selected New York State Prevention Agenda Disparities 25 X X

Health Needs Not Addressed 25 X

4 Implementation Plan

Identification of Resources to Address Community Health Needs 26 X

Existing and Continuing Programs and Interventions 26 X

Inventory of Community Health Activities Completed, Ongoing, and Planned 27 X

Work Plan for Addressing New York State Prevention Agenda Priorities 34 X

5 Ongoing Engagement with Partners and Communities Served 43 X X

6 Dissemination and Awareness of the CHNA/CSP 43 X X

Appendices

A: Data Sources 44

B: Maimonides Community Health Internal Coordinating Committee Roster 45

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Foreword This document serves several functions and meets legal and regulatory requirements for Maimonides Medical Center (Maimonides, or MMC). In its entirety, it is referred to throughout as a “Community Health Needs Assessment and Community Service Plan” or “CHNA/CSP.” The document contains component material which may separately be referred to, in the document or elsewhere, by the following terms:

Community Health Needs Assessment (CHNA) as defined by the Federal Government

Implementation Plan (IP) as defined by the Federal Government

Community Service Plan (CSP) as defined by the State of New York

Community Health Implementation Plan (CHIP) as defined by the State of New York This document describes:

Activities Maimonides undertook during and prior to 2016 to assess the health needs of its community in partnership with other organizations and members of the community

Findings from those activities about the health needs of its community

Activities Maimonides conducted during and/or prior to 2016 that address those findings and/or the findings contained in its prior CHNA approved in 2013

Activities Maimonides will conduct in 2017-2018 to address the findings in this CHNA Maimonides wishes to acknowledge the work of Sylvie Doppelt and Kalpana Bhandarkar in the creation of this report, along with members of the Maimonides Community Health Internal Coordinating Committee, a roster of which is found in Appendix B.

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Executive Summary Maimonides Medical Center (Maimonides or MMC) is a 711-bed specialty care teaching hospital in Borough Park, Brooklyn that treats over 43,000 inpatients per year – more than any other hospital in Brooklyn. MMC serves patients from all over the borough and beyond. Its primary and secondary service areas cover most of Southern Brooklyn, and for this document are defined as including the following New York City Community Districts: Borough Park, Sunset Park, Bensonhurst, Bay Ridge/Dyker Heights, Coney Island, Sheepshead Bay, and Flatbush/Midwood (collectively referred to as MMC’s service area). The service area’s communities are incredibly diverse and include large immigrant populations; 45% of residents were born outside the United States. In 2016 Maimonides undertook a process to assess the health needs of these communities, drawing on direct input from local residents and from information generated by other organizations that serve these communities. The assessment revealed various degrees of healthcare access, healthy behaviors, health conditions, and health outcomes across the service area, including many instances of unmet needs and cases where the service area community, in whole or part, fares worse than New Yorkers on average with respect to health. Based on the community’s measurable health needs, Maimonides’ distinct competencies and resources, and the direct input of community members and partners, Maimonides has elected to focus on the following New York State Department of Health Prevention Agenda priorities (“Prevention Agenda priorities”):

Prevent Chronic Diseases

Promote Healthy Women, Infants and Children

Promote Mental Health and Prevent Substance Abuse

Within the framework of the Prevention Agenda priority to prevent chronic diseases, Maimonides has identified diabetes and obesity in the Hispanic community as a health disparity to address. 17% of the residents of MMC’s service area are Hispanic, including 44% of Sunset Park residents. Hispanics experience much greater rates of childhood obesity, diabetes incidence, and diabetes-related mortality than do non-Hispanic Whites. In addition, MMC continues to identify low rates of vaccination – in particular flu vaccination – as a disparity affecting multiple communities within its service area. These priorities remain consistent with those previously selected by MMC and reported in its 2013 Comprehensive Community Service Plan (CCSP). To confirm these priorities MMC reviewed health and related data from several sources including:

New York City Department of Health and Mental Hygiene (DOHMH) Community Health Profiles

Take Care New York 2020 Community Consultations Conducted by DOHMH

New York City Health Provider Partnership Brooklyn Community Needs Assessment

U.S. Census Bureau American Community Survey (ACS)

New York State Cancer Registry

MMC Finance Department / Patient Registration Data

To more deeply understand the health challenges facing its communities, Maimonides sought input from members of the community through multiple mechanisms including:

Convening a series of public deliberation sessions involving community members

Interviewing leadership of community-based organizations

Convening a meeting of the MMC Council of Community Organizations (COCO) to gain feedback from community and faith-based leaders, elected officials, healthcare providers and public health specialists

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Maimonides works closely with a large number of partner organizations in assessing its community’s health needs and in implementing programs that are responsive to those needs. For the qualitative portion of the needs assessment MMC partnered with the New York Academy of Medicine (NYAM) to conduct the public deliberations and stakeholder interviews referenced above, an endeavor that was funded by the Agency for Healthcare Research and Quality (AHRQ). On an ongoing basis MMC works with the following types of organizations both to understand the health needs of the people it serves and to conduct programming:

Faith-based organizations

Public and non-profit social services providers e.g. senior centers, recreation centers

Public schools

Community associations & boards

Elected officials

Public health officials These organizations often provide space, event promotion, cultural and linguistic expertise, and other assets. Maimonides engages its broader community through events held with organizations like those described above, stakeholder interviews, structured deliberations like the one which was conducted as an input to this assessment, COCO meetings, and other forums. Maimonides has undertaken in 2016, and will implement in 2017-18, a range of interventions to address the three priorities and one health disparity that it is highlighting in this report, as well as many other initiatives that are inventoried in Section 4 below. These initiatives were selected based on MMC’s institutional competencies and capacity; input from community members and partner organizations; and ability to deliver meaningful, measurable interventions. They include:

Priority Area or Disparity Examples of Interventions & Strategies

Prevent Chronic Diseases Lung and colon cancer screening programs

Family Health Challenge

Disparity: Prevent Diabetes & Obesity in the Hispanic Community

Symposia led by dietician or physician in community settings

"¡Vida SI, Diabetes NO!" initiative


Pursue baby-friendly practice and hospital designations

Provide volunteer doulas to pregnant women and families

Promote Mental Health and Prevent Substance Abuse

Participate in DSRIP-funded 100 Schools Initiative to make mental health services more accessible to children

Provide LCSWs to operate in primary care practices

To measure the progress associated with each of these initiatives, the lead organization or MMC department tracks event frequency, participation, and, where applicable, measures of comprehension, awareness, attitudes toward health, or behavior modification. MMC will continue to engage closely with the people it serves, directly and through community representatives, to evaluate the effectiveness of its programs and continue to develop new ways to positively impact health in Southern Brooklyn.

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1. Maimonides Medical Center and its Community About Maimonides Medical Center Maimonides Medical Center (Maimonides or MMC) is a 711-bed specialty care teaching hospital in Borough Park, Brooklyn, the most populous borough in New York City. Maimonides offers a number of nationally-recognized and accredited centers of excellence including a Heart and Vascular Center, Brooklyn’s largest and only full-service outpatient Breast Center and Cancer Center, and a Stroke Care Center. MMC has the borough’s only fully accredited children’s hospital, a Regional Perinatal Center serving high risk neonates, and the State’s largest Obstetrics program, delivering more than 8,600 babies each year. In August 2016, MMC received provisional status as an Adult and Pediatric Trauma Center, becoming Brooklyn’s only Pediatric Trauma Center. On an annual basis, the Medical Center has more than 43,000 inpatient discharges – more than any other hospital in Brooklyn – as well as 120,000 Emergency Department visits and 300,000 outpatient visits. Maimonides has 10 hospital-based outpatient centers, delivering primary and specialty care, dental services, and behavioral health care services. Over 80% of inpatients are covered through government insurance programs – Medicaid or Medicare – and Maimonides treats all patients, regardless of ability to pay. Maimonides is also one of the largest independent teaching hospitals in the country, with 23 accredited residency programs across all major services lines, training 480 interns, residents, and fellows each year. MMC’s Community: Definition and Characteristics Maimonides’ catchment area goes well beyond its immediate neighborhood. It treats a large number of patients from all parts of Southern Brooklyn, and serves patients from across the borough, Staten Island, and beyond. The neighborhoods in which the majority of Maimonides’ patients collectively live, and which compose Maimonides’ primary and secondary service areas include Borough Park, Sunset Park, Bensonhurst, Bay Ridge, Dyker Heights, Bath Beach, Gravesend, Coney Island, Brighton Beach, and Midwood.

MMC Inpatient Origin by Zip, 2015

Zip

MMC 2015

Discharges

% of

Total

United Hospital Fund

Neighborhood Name

11219 7,174 16.7% Borough Park

11220 3,854 9.0% Sunset Park

11230 3,160 7.3% Borough Park

11204 3,065 7.1% Borough Park

11218 3,054 7.1% Borough Park

11214 2,920 6.8% Bay Ridge & Bensonhurst

11223 1,844 4.3% Coney Island

11235 1,607 3.7% Coney Island

11229 1,550 3.6% Coney Island

11224 1,253 2.9% Coney Island

11226 1,232 2.9% Flatbush



All Other 10,122 23.5%

Total 43,010 100.0%

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Map of MMC Inpatient Origin by Zip, 2015

Source: AHS Patient Registration Data for CY15, MMC Finance

The Medical Center’s service area is one of the most racially and ethnically diverse in New York City. Maimonides’ patient population includes large numbers of Orthodox Jews, Chinese, Latino, Russian, Caribbean, and South and Southeast Asian (primarily Pakistani, Bangladeshi, Indian, Laotian, Filipino, and Indonesian) residents. The borough’s rich diversity is reflected in Maimonides’ inpatient and outpatient populations.

Maimonides Inpatient Demographic Breakdown, 2015

Race/Ethnicity Count %

White 20,943 59%

Black / African American 4,008 11%

Asian 6,791 19%

American Indian/Alaska Native 19 0%

Other/Unknown 3,747 10%

Race/Ethnicity Count %

Hispanic or Latino (any race) 4,120 11%

Not Hispanic or Latino 27,005 75%

Unknown 4,887 14% Source: Demographic Data from AHS/MMC MIS

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The quantitative component of this assessment draws on the New York City Department of Health and Mental Hygiene’s (DOHMH) Community Health Profiles published in October 2015. The DOHMH profiles define communities based on the same boundaries used by New York City Community Board Districts; there is one profile for each community district. This document uses data for seven Brooklyn community boards that roughly correspond to its primary and secondary services areas, as depicted below.

NYC Community Districts Included in this Needs Assessment

Neighborhoods Included in Community Districts (CDs) Used in this Assessment

Over 1.1 million people live in these seven communities. Nearly half (approx. 45%) of the population is foreign-born, including many undocumented immigrants. 52% are white, 21% are Asian, 17% are Hispanic, and 8% are black. The areas Maimonides serves rank consistently high in rates of household poverty and lower levels of education. 37% of the residents in these communities have limited English proficiency.

CD # CD Name Neighborhoods Partially or Wholly Contained Within the CD

7 Sunset Park Sunset Park, Windsor Terrace

10 Bay Ridge & Dyker Heights Bay Ridge, Dyker Heights, Fort Hamilton

11 Bensonhurst Bensonhurst, Bath Beath, Gravesend, Mapleton

12 Borough Park Borough Park, Kensington, Ocean Parkwwy

13 Coney Island Coney Island, Gravesend, Homecrest, Sea Gate, West Brighton

14 Flatbush & Midwood Flatbush, Midwood, Ditmas Park, Manhattan Terrace, Ocean Parkway, Prospect Park South

15 Sheepshead Bay Sheepshead Bay, Gerritsen Beach, Gravesend, Homecrest, Kings Highway, Manhattan Beach, Plumb Beach

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MMC Service Area Population Snapshot

Foreign-Born, Limited English Proficiency, Age 65+, Race/Ethnicity

Neighborhood % Foreign

Born

% Ltd English

Racial/Ethnic Breakdown*

% Over 65 White Asian Hispanic Black Other

New York City 37% 23% 33% 14% 29% 23% 2% 14%

Brooklyn 38% 24% 36% 11% 20% 31% 2% 12%

Borough Park 32% 32% 64% 19% 13% 2% 2% 10%

Sunset Park 47% 47% 24% 28% 44% 3% 1% 9%

Bay Ridge and Dyker Heights

38% 28% 60% 22% 15% 1% 2% 14%

Bensonhurst 55% 47% 48% 36% 13% 1% 2% 15%

Coney Island 55% 46% 57% 13% 17% 13% 0% 21%

Flatbush and Midwood

45% 28% 37% 10% 16% 36% 1% 12%

Sheepshead Bay 46% 31% 71% 16% 8% 3% 2% 16% *Categories other than Hispanic represent non-Hispanic members of the indicated racial group eg White Non-Hispanic

(Source: DOHMH Community Health Profiles, 2015)

Maimonides’ Engagement with its Community Community engagement as a means of fostering healthy communities has been a key priority at Maimonides for decades. Maimonides’ Community Relations department has built strong partnerships with community- and faith-based leaders, elected officials, and community boards, along with key community organizations that collectively represent a broad base of the residents of South Brooklyn. In addition to co-hosting health fairs and educational symposia in community-based settings, Maimonides recruits patient representatives from diverse communities in its catchment area – often those that are bilingual – to serve as liaisons and patient navigators during a patient’s inpatient, outpatient or Emergency Department visit. Maimonides also hosts one of the country’s largest hospital volunteer programs, training and deploying 1,800 volunteers across the hospital annually. Every year Maimonides hosts one to two meetings of the Council of Community Organizations (COCO), a group of faith- and community-based groups and leaders from in and around the communities it serves. Present at these meetings are rabbis, imams, pastors, community-based leaders, health care providers, area residents, and elected officials. Agenda items cover new initiatives at the hospital and in the community aimed at improving health and wellbeing, including prevention-oriented programming, and open dialogue about health-related issues. To formally evaluate the met and unmet healthcare needs of the communities it serves, Maimonides conducted a comprehensive community health needs assessment in 2013-14, and has done so again over this past year, in an effort to better understand the communities within its service areas. This CHNA is composed of both a quantitative component (a review and analysis of key health indicators) and a qualitative component (Public Deliberations and key informant interviews), that focus on resident health needs, priorities and behaviors, as well as social and economic determinants of health. Community Care of Brooklyn (CCB): Overview and Alignment with MMC’s Community Health Program While the majority of patients Maimonides serves reside in Southern Brooklyn, Maimonides’ efforts to foster healthy communities and improve the healthcare delivery system reach beyond its primary and secondary service areas. Leveraging its experience developing and implementing collaborative care models and broad health

http://www1.nyc.gov/site/doh/data/data-publications/profiles.page

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coalitions, Maimonides is playing a leadership role in the transformation of Brooklyn’s healthcare delivery system, in particular for Medicaid enrollees. Maimonides is the fiduciary for Community Care of Brooklyn (CCB), which is the largest Performing Provider System (PPS) in Brooklyn. PPS entities were established as part of New York State’s Delivery System Reform Incentive Payment (DSRIP) program. As described in the DSRIP Brooklyn Community Needs Assessment (CNA):

In April, 2014, New York State finalized a waiver amendment from the Centers for Medicaid and Medicare Services that allows for reinvestment of approximately $8 billion in projected savings resulting from the State’s Medicaid Redesign Team reforms. These funds will be used to support transformation of the health care system in NYS to promote clinical and population health. The majority of the funds will be distributed through a Delivery System Reform Incentive Payment (DSRIP) program. A central part of DSRIP is the formation of Performing Provider Systems (PPS) - collaborative partnerships between hospitals, community-based organizations, and other health care providers across the full spectrum of care. The goal of DSRIP is to advance innovative projects designed to transform the safety net health care delivery system, improve population health, and reduce avoidable hospitalizations. (DSRIP CNA, 8)

Through DSRIP, CCB is responsible for managing care for 600,000 Medicaid beneficiaries – nearly half of the Medicaid beneficiaries in Brooklyn and 10% of the total Medicaid population of New York State. The CCB network is comprised of over 4,600 medical practitioners, six hospitals (including Maimonides), ten federally qualified health centers (FQHCs), and 350 social service organizations. Together, this consortium is implementing a coordinated approach to managing the care of chronically ill populations. The PPS is responsible for implementing evidence-based initiatives and integrating primary, specialty and behavioral healthcare in community settings, with hospitals used primarily for emergency and tertiary level services. Through community-level collaborations, the PPS will work to achieve the triple aim of better health, better care, and reduced costs, reduce avoidable inpatient admissions by 25% and decrease emergency room visits over five years. Maimonides is participating in a number of DSRIP projects, and also serves as a tertiary anchor for Brooklyn, providing advanced specialty care services to PPS partners. Maimonides also plays a key role in the Southwest Brooklyn Health Home, an organization it established in 2012, and which was subsequently reorganized as an independent LLC for which Maimonides holds the management contract. In this entity, Maimonides partners with a network of 25+ providers and community-based organizations to coordinate services for Medicaid beneficiaries who have high-cost and complex chronic conditions. This is done primarily through care managers who help members access needed services to stay healthy in the community, aided by an innovative and dynamic health information technology platform. These services include housing, social services, medical and behavioral health, substance use, home care, and family support and education, which are coordinated and integrated to improve health outcomes for this population and control health care costs. .

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2. Identification of Health Needs Quantitative Analysis: Health Indicators & Disparities Methods The October 2015 DOHMH Community Health Profiles include health data on each neighborhood in the City as well as how those neighborhoods compare to the rest of the borough and to New York City. The profiles address both health outcomes as well as social determinants of health such as educational attainment and income levels. Maimonides analyzed data from these profiles, in addition to health indicators from the New York State Prevention Agenda and the U.S. Census. The data below focus on the seven community districts in which the majority of Maimonides patients collectively live. Findings Data from the 2015 DOHMH Community Health Profiles are composed of aggregated data from annual Community Health Surveys from 2011-2013. They revealed trends across neighborhoods in Maimonides’ catchment area, and also showed key differences and unique challenges facing certain neighborhoods, all of which help define the health needs of the community. This report does not focus solely on a single neighborhood; rather, it aims holistically to address both specific and broad health needs across Southern Brooklyn. The primary health challenges facing the communities served by Maimonides involve chronic disease prevention and treatment, which are shown to be influenced by inadequate access to healthcare and healthy foods, and additional social, economic, and cultural factors that influence childhood vaccination, physical activity, nutrition, access to prenatal care, and more.

MMC Service Area: Overall Health Status

Neighborhood Self-Reported Health “Excellent,”

“Very Good,” or “Good”1 Premature Mortality Per

100,0002

New York City 78% 198.4

Brooklyn 75% 194.5

Borough Park 74% 131.6

Sunset Park 68% 148.6

Bay Ridge and Dyker Heights 81% 144.8

Bensonhurst 70% 137.8

Coney Island 65%* 218.8

Flatbush and Midwood 77% 178.5

Sheepshead Bay 64% 148.7

Source: DOHMH Community Health Profiles, 2015 1. Age-adjusted percent of adults responding in this way, on a five-level scale that also includes “Poor” and “Fair” 2. Age-adjusted rate of premature deaths, defined as death < 65 years, per 100,000 population * Interpret Coney Island statistic with caution due to limited sample size or other statistical factor

Social Determinants of Health Chronic disease risk and burden are significantly impacted by social, economic, and environmental factors, such as low incomes, working long hours or multiple jobs, and lack of comprehensive health education. This remains true among the communities that Maimonides serves, as many immigrant and low-income communities report working very long hours, sometimes in multiple jobs, which can make it difficult to maintain healthy habits.


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High poverty rates pose a persistent challenge to healthy living, particularly in Borough Park and Sunset Park, where 32% and 29% of residents, respectively, live in poverty, compared to 24% of residents in Brooklyn and 21% in New York City overall. Low educational attainment in Brooklyn Park and Sunset Park also contribute to poorer health outcomes. Limited access to supermarkets, often linked with diminished access to fresh, affordable and healthy foods was also found to be a barrier, particularly in Bay Ridge/Dyker Heights, Bensonhurst, and Coney Island, according to the DOHMH Health Profiles.

MMC Service Area: Social Determinants of Health

Neighborhood

Housing Defect Rate1

Air Pollution Indicator2

Supermarket Indicator3 Educational Attainment Poverty Rate

New York City 59% 8.6 177 41% col. grad

20% less than HS 21%

Brooklyn 62% 8.7 156 38% col. grad


Borough Park 52% 8.5 164 31% col. grad


Sunset Park 58% 9.2 170 29% col. grad



43% 8.4 85 43% col. grad


Bensonhurst 41% 8.2 83 32% col. grad


Coney Island 56% 8.0 86 42% co. grad

18% less thank HS 27%


72% 8.6 134 41% col. grad


Sheepshead Bay

46% 8.1 150 44% col. grad


Source: DOHMH Community Health Profiles, 2015 1. Percent of renter-occupied homes with at least one maintenance defect. Lower is better. 2. Annual average of micrograms of fine particulate matter (PM 2.5) per cubic meter. Lower is better. 3. Supermarket square footage per 100 population. Higher is better.

High rates of poverty and lower levels of educational attainment – in Borough Park and Sunset Park in particular – as well as insufficient access to supermarkets and fresh foods – particularly impacting Bay Ridge/Dyker Heights, Bensonhurst, Coney Island, Flatbush, and Sheepshead Bay – play a substantial role in the health of communities and impact access to healthy environments and lifestyles. Healthcare Access Lack of access to quality healthcare can lead to negative health outcomes and often means that patients are treated for disease and illness at more advanced stages. Lack of health insurance remains a barrier to care in Maimonides’ services area, where 27% of residents in Sunset Park and Coney Island report having no health insurance, compared to only 20% in Brooklyn and 20% in New York City overall.


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MMC Service Area: Access to Healthcare Neighborhood No Health Insurance1 Went Without Medical Care2

New York City 20% 11%

Brooklyn 20% 12%

Borough Park 20% 10%

Sunset Park 27% 9%

Bay Ridge and Dyker Heights 16% 6%

Bensonhurst 19% 10%

Coney Island 27% 11%

Flatbush and Midwood 24% 15%

Sheepshead Bay 18% 9%

Source: DOHMH Community Health Profiles, 2015 1. Age-adjusted percent of adults that reported not having health insurance 2. Age-adjusted percent of adults that reported needing medical care in the past 12 months but did not

receive it

Immigrant communities, particularly undocumented residents, face magnified barriers to accessing healthcare services, including linguistic and cultural barriers, ineligibility for insurance, and lack of knowledge about where and how to access care in their communities. Due to fear of deportation or arrest, some residents may be less likely to provide personal information that is often required to obtain care. The Medicaid population also has profound challenges obtaining access to preventive care, as detailed in the DSRIP CNA:

There are approximately 1.3 million Medicaid beneficiaries living in Brooklyn, which is 1 out of 5 (21.1%) of all Medicaid beneficiaries in New York State and more than one-third (34.3%) of all Medicaid beneficiaries in New York City. The percentage of the Brooklyn population who are Medicaid Beneficiaries varies across zip codes from 11.8% to 84.9% (See Appendix A, Map 1). The highest proportion of the population who are Medicaid Beneficiaries are in two large clusters, one in the northeast part of the borough from Williamsburg through Bushwick, Bedford-Stuyvesant, Brownsville, and East New York; and the other in southwest and south central Brooklyn, from Sunset Park to Borough Park, Flatbush, East Flatbush, and Bensonhurst. (DSRIP CNA, 28) In 2013, there were approximately 79.5 FTE primary care physicians per 100,000 population in Brooklyn, lower than NYC (90.2 per 100,000) and NYS (84.5 per 100,000) rates for the same time period.1 (DSRIP CNA, 10) A key component of DSRIP is to reduce avoidable services by bolstering primary care providers and community based organizations (CBOs) to enhance coordination of care, prevention and disease management, particularly for those with chronic conditions. We find the distribution of primary care providers uneven in Brooklyn, with sparse numbers in certain neighborhoods....2 The data also suggest there is a lack of culturally and linguistically competent specialists and multi-specialty centers that could provide a ‘one-stop shopping’ experience that many patients seek.3 (DSRIP CNA, 4)

Health Behaviors Health behaviors vary widely across different neighborhoods of Southern Brooklyn. Key data reveal behavior trends that may influence residents’ risk of developing chronic disease. In particular, relatively high adult smoking rates and lack of regular physical activity impact health in Maimonides’ communities, and are linked with high blood pressure, diabetes, and some cancers.

1 “The Health Care Workforce in New York: Trends in the Supply and Demand for Health Workers” Center for Health Workforce Studies, 2013 data, published June 2014 2 NYAM Primary Data Collection, preliminary findings, August, 2014. Brooklyn Healthcare Improvement Project (B-HIP) “Final Report: Making the Connection to Care in Northern and Central Brooklyn,” August, 2012. 3 Ibid.


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MMC Service Area: Healthy Behaviors

Neighborhood Current Smokers

> 1 Sugary Drink/Day

At Least 1 Fruit or Veg./Day

Physical Activity in Last 30 Days

New York City 15% 27% 88% 77%

Brooklyn 16% 27% 87% 75%

Borough Park 14% 22% 89% 72%

Sunset Park 15% 29% 87% 67%


14% 21% 89% 77%

Bensonhurst 18% 22% 93% 69%

Coney Island 18% 26% 92% 71%


14% 28% 84% 79%

Sheepshead Bay 19% 25% 89% 73%

Source: DOHMH Community Health Profiles, 2015

Chronic Diseases The predominant primary health challenges among the communities Maimonides serves center around chronic disease prevention and treatment. The leading causes of death across southern Brooklyn are heart disease and cancer. High rates of obesity, which can lead to heart disease, diabetes, and other chronic illnesses, as well as high blood pressure and high cholesterol, are seen across Maimonides’ service areas, with the highest rates in Coney Island and Sheepshead Bay. Diabetes rates in the Maimonides service area are fairly consistent with rates across Brooklyn and New York City, and have a profound impact on the health and well-being of residents.

MMC Service Area: Obesity and Diabetes

Neighborhood Obesity Rates Diabetes Rates


Brooklyn 27% 11%

Borough Park 23% 9%

Sunset Park 19% 9%


Bensonhurst 23% 9%





The health impacts of obesity and diabetes in Maimonides’ service area are consistent with the broader trend in the borough:

Diabetes is considered by many residents and key informants to be the most significant health issue in Brooklyn. The number of beneficiaries in Brooklyn who had a diabetes-related service utilization totaled 139,755 in 2012, representing 11.3% of the beneficiary population. The proportion of the population with a diabetes-related service ranged from 6.2% to 28.7% across Brooklyn zip codes. (DSRIP CNA, 49)



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Cancer is the second leading cause of death across neighborhoods in Maimonides’ catchment area. According to the New York State Department of Health, New York City Cancer Registry, the highest rates of incidence are seen for the following cancer types in both male and female: colorectal, lung and bronchus, female breast, and prostate. Note that female breast is the highest cancer incidence in females across all neighborhoods studied. Prostate cancer is the highest cancer incidence for males, across all neighborhoods studied.

MMC Service Area: Cancer Rates by Neighborhood

Borough Park 11219

Southwest Brooklyn

11209, 11228, 11204

Flatlands, Canarsie, Mill Basin

11234, 11236,11239

Sunset Park 11220, 11232

Central Brooklyn

11213, 11216, 11218, 11223

Flatbush 11203, 11210, 11225, 11226

Top 5 Highest Cancer Incidence in MALES

Prostate 152.0

Prostate 108.6

Prostate 194.4

Prostate 40.4

Prostate 260.6

Prostate 307.0

Lung & Bronchus 92.2

Lung & Bronchus

79.8


Lung & Bronchus

31.4

Lung & Bronchus

78.4

Colorectal 60.6

Colorectal 71.2

Colorectal 55.4

Colorectal 48.8

Colorectal 29.8

Colorectal 64.4


Urinary Bladder 54.2


Colon (excluding

rectum) 34.4

Colon (excluding rectum)

19.2

Colon (excluding

rectum) 43.6

Colon (excluding

rectum) 46.0

Colon (excluding rectum) 47.8

Colon (excluding

rectum) 38.4


Liver /intrapatic bile duct

16.6

Non-Hodgkin lymphomas

27.4

Myeloma 17.2

Top 5 Highest Cancer Incidence in FEMALES

Female Breast 185.0

Female Breast 156.0

Female Breast 152.0

Female Breast 58.8

Female Breast 199.0

Female Breast 204.2

Colorectal 75.0

Lung & Bronchus

71.4

Colorectal 49.6

Thyroid 27.4

Colorectal 72.2

Corpus uterus & NOS 66.4

Thyroid 70.4

Colorectal 57.8


Colorectal 24.4

Lung & Bronchus

67.0

Colorectal 65.6


Thyroid 46.4


Lung & Bronchus

22.2



Colon (excluding rectum) 55.8

Colon (excluding

rectum) 45.0

Colon (excluding rectum)

38.2

Colon (excluding

rectum) 16.6

Colon (excluding

rectum) 56.6

Colon (excluding

rectum) 48.0

* New York State Cancer Registry Data, 2008 – 2012. Rate per 100,000. Listed from most to fewest annual cases.

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In addition to their impact on individuals and communities, chronic diseases tend to tax the resources of local healthcare systems. As noted in the Brooklyn CNA:

In Brooklyn, the greatest proportion of potentially preventable admissions (PQI) is for chronic conditions including respiratory conditions such as asthma, cardiovascular conditions such as hypertension, and diabetes; these conditions and diseases represent the areas of opportunity for reducing preventable inpatient stays. 4 (DSRIP CNA, 4) The highest Observed / Expected PQI ratios are consistently found in north-central Brooklyn... and in Coney Island. (DSRIP CNA, 35) In 2012, the number of potentially preventable hospitalizations among Medicaid beneficiaries for circulatory conditions (PQI S02 Circulatory Composite) in Brooklyn was 3,694, accounting for more than one in five (23.3%) of all such admissions in the State. However, the ratio of observed/expected (O/E) admissions in Brooklyn (1.04) was lower than the ratio for NYC (1.06) for the same time period. At the zip code level within the borough, the highest Observed / Expected PQI ratios for Circulatory Composite are in north-central Brooklyn…and in Flatbush, East Flatbush, and Coney Island - Sheepshead Bay. (See Appendix A. Map 39, and table below.) (DSRIP CNA, 51)

Prevention and Screening Neighborhoods around Maimonides’ service area have some of the lowest rates of vaccination for HPV and flu in the city, as well as for cancer screening. Refusal to immunize children can be partially attributed to concerns and misinformation about vaccines. Additionally, limited focus on prevention, and the tendency to not seek medical or preventive care when people feel healthy, impact low vaccination levels in the community.

MMC Service Area: Vaccination Neighborhood HPV Vaccination Flu Vaccination


Brooklyn 36% 36%

Borough Park 20% 33%

Sunset Park 53% 39%


Bensonhurst 34% 34%





Cancer Screening The charts below that depict rates of screenings for colon and breast cancer in 2012 by neighborhood reveal low rates of screening across several neighborhoods in Maimonides’ catchment area, particularly Borough Park, Bensonhurst/Bay Ridge, and East Flatbush/Flatbush. Low screening rates is an additional risk factor for high cancer incidence.

4 The rate of potentially preventable inpatient admissions for chronic conditions (PQI 92) is 1,283 per 100,000 Medicaid beneficiaries in Brooklyn versus 480 per 100,000 beneficiaries for acute conditions (PQI 91). However, this measure does not assess length of stay or cost for these admission types.


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Maternal & Infant Health Indicators of maternal and infant health vary greatly across Maimonides’ service area. In Maimonides’ primary service areas of Borough Park and Sunset Park, rates of late/no prenatal care and of infant mortality are among the lowest in the City. In areas more distant from the hospital such as Coney Island, Flatbush, and Midwood, these indicators are at or above (worse) than the citywide averages.

MMC Service Area: Maternal & Infant Health

Neighborhood Late/No Prenatal Care

Rate1 Preterm Birth

Rate2 Teen Births Per 1,0003

Infant Mortality Per 1,0004

New York City 7.4% 9.0% 23.6 4.7

Brooklyn 6.4% 8.8% 24.0 3.9

Borough Park 2.7% 6.4% 19.3 1.7

Sunset Park 3.3% 7.2% 33.2 1.6


6.1% 7.0% 14.0 2.5

Bensonhurst 5.3% 7.3% 14.7 3.9

Coney Island 11.0% 11.3% 25.8 5.5

Flatbush and Midwood 7.7% 8.5% 20.0 4.0

Sheepshead Bay 5.9% 7.3% 14.2 2.6

Source: DOHMH Community Health Profiles, 2015 1. Percent of live births receiving late prenatal care (i.e., after the first and second trimesters) or no prenatal care 2. Percent of preterm births (<37 weeks gestation) among all live births 3. Rate of births in which the mother is under 20 years old per 1,000 women ages 15-19 years 4. Rate of deaths of infants under one year old per 1,000 live births

Mental Health & Substance Use Mental health is less emphasized than physical health in the DOHMH Community Health Profiles, but the DSRIP Brooklyn CNA contains a number of important findings about the extent of mental health needs in the borough and in specific communities that Maimonides serves:

Among the Brooklyn population as a whole, the age-adjusted percentage of adults with poor mental health for 14 or more days of 7.4%, as well as the age-adjusted suicide rate of 4.6%, were lower than the state and city rates. 6.1% of all people in Brooklyn report experiencing serious psychological distress, compared to 5.5% in NYC overall. In NYC, people who are currently experiencing psychological distress are more likely to report binge drinking in the last 30 days than people who did not report psychological stress and are more than twice as likely to report being a current smoker. Coney Island, in particular, appears to be disproportionately impacted by psychological distress with 12% of residents reporting it, nearly double the rate for the Borough (6.0%). Those in Bay Ridge/Bensonhurst and Williamsburg/Bushwick also report high rates of psychological distress, with approximately one in ten residents surveyed reporting it. (See table, Appendix B.) (DSRIP CNA, 42) Access to mental health services is reported to be limited, although it might be the case that community organizations and residents are not aware of available services or how to access them. In addition, behavioral health issues generally carry greater stigma than other health concerns, which tends to limit use of services. Key informants and focus group participants both reported that many affected families try to address

problems internally.5 (DSRIP CNA, 42)

5 Ibid.


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Many patients with behavioral health conditions also have chronic physical health conditions. According to data from the NYS Office of Mental Health (OMH), approximately 55% (13,141/23,994) of Brooklyn clients served had at least one chronic medical condition. (See table and chart, Appendix B.) The 2011 PCS found that 51.5% of Brooklyn Adults surveyed had cardiac or metabolic illnesses; and 10.4% of Brooklyn children surveyed had a pulmonary condition. Chronic physical illness co-morbidities are clearly a significant factor in the health of behavioral health patients in Brooklyn. Looking at Brooklyn inpatient hospital admissions by zip code for beneficiaries who have utilized some mental health services in the 2012 calendar year, including behavioral health prescription medicines we see a geographic pattern of hospital admissions very similar to the Chronic Disease Composite PQI (PQI 92) map. This is consistent with the literature noting that the majority of inpatient admissions for beneficiaries with a behavioral health condition are for physical health conditions. (DSRIP CNA, 42)

In recent years Brooklyn has been increasingly impacted by the growth in opioid use and addiction that has been experienced across the U.S. This trend is evident in the use of hospital emergency departments, among other indicators, and reflects increases in addiction to both heroin and prescribed opioid analgesics.

Opioid-Related Emergency Department Admissions by County of Residence, 2010-2014

Area

Rate Per 100,000 Population % Chg 2010-14 2010 2011 2012 2013 2014

New York State 112.5 133.5 162.5 175.0 194.8 73.1%

Brooklyn 133.2 157.5 174.3 169.2 206.6 55.1%

Source: New York State Opioid Poisoning, Overdose and Prevention: 2015 Report to the Governor and NYS Legislature, NYS DOH

While this trend represents a growing health need, the communities in Maimonides’ service area experience relatively low rates of drug-related hospitalizations as compared to borough-wide and citywide average rates.

MMC Service Area: Drug-Related Hospitalizations

Neighborhood Drug-Related Hospitalizations

Per 100,0001

New York City 907

Brooklyn 921

Borough Park 272

Sunset Park 529

Bay Ridge and Dyker Heights 370

Bensonhurst 267

Coney Island 860

Flatbush and Midwood 649

Sheepshead Bay 314

Source: DOHMH Community Health Profiles, 2015 1. Age-adjusted rate of drug-related hospitalizations per 100,000 adults

http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/docs/annual_report2015.pdf

http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/docs/annual_report2015.pdf


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Qualitative Component: Public Deliberations Overview To more deeply understand the health challenges and needs facing our communities, Maimonides sought input from members of the community who represent the broad interests of the community through multiple mechanisms including:

Partnering with the New York Academy of Medicine to convene and facilitate deliberative public deliberation sessions, described below;

Interviews with leadership at community-based organizations and local community boards; and

Convening a meeting of the Council of Community Organizations (COCO) to gain feedback from community and faith-based leaders, elected officials, healthcare providers and public health specialists

Additionally, Maimonides has engaged in numerous conversations with staff in NYC Department of Health and Mental Hygiene’s Center for Health Equity, including with Dr. Torian Easterling, the Commissioner for the Brooklyn District Public Health Office, as well as with the Director of Nutrition and Physical Activity at the Brooklyn District Public Health Office. These discussions addressed community health needs, programs and initiatives the DOHMH were establishing, opportunities to partner on Brooklyn public and community health initiatives, and feedback on Maimonides’ strategy. Public Deliberation Methods Beginning in the fall of 2015, with funding from the Agency for Healthcare Research and Quality (AHRQ), The New York Academy of Medicine (The Academy) and Maimonides Medical Center hosted Prioritize Health! a public deliberation model to elicit recommendations for Maimonides focused on preferred approaches to prevent chronic disease. The New York Academy of Medicine convened and facilitated three 2-day deliberative sessions to elicit recommendations for Maimonides Medical Center focused on approaches to prevent chronic disease within the communities they serve. Public deliberation is a method of engaging a group of community members in informed discussion in order to provide advice to institutions and/or policy makers that are considering a complex, value-laden decision that lacks a technical solution.7,11 As part of the deliberative process, participating community members receive relevant background information and hear presentations that allow them to explore the different considerations that are relevant to a decision making context. Participants interact with the facilitators, the presenters, and—most importantly—with one another as they consider case studies and/or exercises developed to facilitate discussion that will elucidate preferences, priorities and recommendations for the sponsoring institution or policy maker. Deliberative sessions typically pose specific questions to participating community members, which articulate the decision the sponsoring institution or policy maker is considering.

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Each deliberative session involved 21-24 participants who were selected from a group of nearly 300 Brooklyn residents that completed screening forms for the project. Extensive outreach was conducted to identify participants, including phone calls to community members that have previously participated in Maimonides community programming; signs in libraries and other public places; engagement of local elected officials to assist with dissemination of information; announcements on social media sites including Facebook, Twitter and craigslist; and outreach at health fairs, libraries and to community organizations serving diverse populations. Eligibility criteria included Brooklyn resident, age 18 or older, self-reported comfort with English, and a correct response to one numeracy item. Participants were purposefully selected for diversity according to age, race and ethnicity, educational attainment, and neighborhood, as reported on the screening form. (see Tables 1 and 2 for participant characteristics). The deliberative sessions were framed around two main questions that participating community members considered. The questions were intentionally framed broadly such that the hospital would have general guidance to approaches favored by the community, but not be constrained by highly specific recommendations. The questions were:

1. Should Maimonides’ efforts to improve health focus primarily on:

a. Improving prevention services delivered by medical staff in the hospital’s clinics

b. Community interventions that decrease risk factors for disease;

c. Working to change policies (e.g., of the government, of employers, of schools) that make it easier for people to stay healthy

2. Should Maimonides’ concentrate its efforts to prevent disability and disease primarily on:

a. Children b. Working age adults c. Older individuals d. People who have the highest risk for

early disability or death due to their living circumstances.

n (%)

Age

18-34 11 (16.7%)

35-49 13 (19.7%)

50-59 13 (19.7%)

60-74 21 (31.8%)

75 and older 8 (12.1%)

Education

Less than HS Graduate 2 (3.0%)

HS Graduate or GED 9 (13.6%)

Some College but no Degree 17 (25.8%)

College Degree or Higher 38 (57.6%)

Gender

Male 22 (33.3%)

Female 44 (66.7%)

Race/Ethnicity*

White 34 (51.5%)

Black or African American 13 (19.7%)

American Indian/Native American 1 (1.5%)

Hispanic/Latino 6 (9.1%)

Asian/Asian American 7 (10.6%)

Arab/Arab American 1 (1.5%)

Missing 4 (6.1%)

Religion*

Christian/Catholic 32 (48.5%)

Jewish 10 (15.2%)

Muslim 3 (4.6%)

Other 6 (9.1%)

No religion 7 (10.6%)

Missing 8 (12.1%)

Full Time 15 (22.7%)

Part Time 15 (22.7%)

Retired 23 (34.9%)

Not working 7 (10.6%)

Homemaker/ Caregiver 2 (3.0%)

Other 3 (4.6%)

Table 1: Prioritize Health!

Characteristics

Employment Status*

* Percents do not add to 100 due to missing values

Demographic Characteristics (N=66)

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In advance of each deliberative session, participants were furnished with background materials that provided context for the deliberation (see Appendix A). Deliberative sessions were facilitated by Academy staff and an expert consultant. Each included presentations to participants on health characteristics (e.g. obesity, cardiovascular disease), behavioral risk factors (e.g. physical activity and fruit and vegetable consumption), and social and environmental risk factors (e.g. education, community resources) (see Appendix B). In addition, each included educational presentations (in person or by teleconference) by recognized experts in the field (see Appendix C), which focused on the different approaches to prevention: clinical, community and policy. Small and large group discussions throughout the two days allowed participants to explore and discuss—with the facilitators, and with one another—a variety of approaches to chronic disease prevention, targeting different populations and/or operating at different levels (i.e., clinical, community or policy) (see Appendix D). All approaches presented were built from evidence-based reviews conducted by the U.S. Preventive Services Task Force, the Community Guide to Prevention and/or Cochrane reviews. Findings The public deliberation sessions and key informant interviews strongly aligned with the findings from the Community Health Profiles, and input from the sessions is summarized below. Participants cited the limited access to healthy and affordable foods, noting that for many community members it is too expensive to eat well, fast food options are too prevalent and available, and parents often do not have enough time to cook nutritious meals. As a result, one participant said, families end up having to serve packaged and fast food meals. Among children, participants said, it is particularly important to enhance access to healthy foods, as school meals are unhealthy, and “even when there are healthy options, kids still choose junk food.”

Children seem to be a very vulnerable group today. They are getting sicker. They are obese. I think that there are a lot of organizations in the community where you can – Maimonides can impact with and maybe get the children to learn how to eat better, how to have better health habits despite their living conditions and also Maimonides might be able to send some speakers to a school… I think children are a real important target group and I think sometimes the parents can’t do it. They’re too busy, they’re not knowledgeable enough, they rely on quick fixes, they take their kids to fast food places, etc.

n (%)

United Hospital Fund Neighborhood

Coney Island-Sheepshead Bay 20 (30.3%)

Bensonhurst-Bay Ridge 9 (13.6%)

Borough Park 8 (12.1%)

Downtown-Heights-Park Slope 7 (10.6%)

Canarsie 6 (9.1%)

Sunset Park 4 (6.1%)

Flatbush 4 (6.1%)

Williamsburg-Bushwick 4 (6.0%)

Bedford Stuyvesant-Crown Heights 3 (4.6%)

Greenpoint 1 (1.5%)

Table 2

Neighborhoods Represented

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Participants also highlighted the need for enhanced education on the health impacts of diet and exercise, as well as more opportunities to be physically active, particularly for working-age adults, for whom, one participant said, there are “not many options for this age group.” Many participants also said that high rates of diabetes, among both children and adults, are a persistent and growing problem in their communities, due in part to lack of proper nutrition and physical activity. Environmental circumstances also proved an important set of challenges among Public Deliberation participants, some of whom noted limited park access in their neighborhoods and a need for safe outdoor space. Finally, stress and other mental health challenges arose as a consistent theme across Public Deliberation sessions, with participants noting high prevalence of substance use and addiction, including among teenagers. This concern was also echoed by the Arab American Association of New York and the Salam Arabic Lutheran Church. The root causes of stress that participants noted included poverty, stress of having multiple jobs/working long hours while caring for a family, neighborhood violence, and overcrowding and traffic in neighborhoods were all mentioned as consistent challenges. Working such long hours or having multiple jobs can make is difficult to maintain healthy eating and physical activity habits, and also inhibit regular access to primary care. Isolation, especially among older adults, and challenges associated with accessing transportation to community centers or other opportunities for socialization were discussed. Qualitative Component: Interviews Methods Key informant interviews with community groups representing a diverse range of population groups and broad interests, were conducted. These were semi-structured conversations, and addressed various topics including health challenges, trends in healthcare needs, unique health needs of communities across ethnicities and religions, perceptions and usage of healthcare organizations, and opportunities to strengthen engagement in preventive health. Five interviews were conducted, and participants were identified in collaboration with the Maimonides Patient and Community Relations Department. Organizations and community groups interviewed include:

Arab American Association of New York

Community Board 11, representing the neighborhoods of Bensonhurst, Bath Beach, Gravesend, and Mapleton

Community Board 14 Human Services Committee, representing the neighborhoods of Ditmas Park, Flatbush, Manhattan Terrace, Midwood, and Ocean Parkway

Nia Community Services Network

Salam Arabic Lutheran Church Notes from the meetings were taken, and their input is summarized below. Findings The community organizations and community board representatives addressed barriers to making healthy lifestyle choices including limited access to supermarkets and limited number of channels through which residents can enroll in SNAP Benefits (CB14). Additionally, in certain cultures, including among Arab-American communities, physical activity is sometimes not emphasized and difficult to engage in, and is “almost non-existent,” one community member said. Some people will not attend co-ed gyms, and the financial burden of joining a gym or attending fitness classes is sometimes not feasible for residents. High prevalence of diabetes, sometimes as a result of inadequate nutrition and physical

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activity were also cited. Nutritional issues are seen to stem from both lack of awareness and understanding of healthy eating habits as well as rooted in poverty and access. Long working hours, large family size, and low incomes present barriers to healthy eating habits, and adults often have limited time to shop and cook, and fast food is the often the feasible alternative. Additionally, cultural traditions influence food choice and perceptions of healthy weight. For instance, among certain cultures, being “big” is encouraged and an indicator of success and prosperity. The diversity of South Brooklyn poses specific challenges with respect to health services. Large numbers of immigrants – including many undocumented – are faced with healthcare access barriers, including linguistic, eligibility for insurance, and more. Community leaders and community board representatives noted high smoking rates, particularly in Middle Eastern and Chinese communities (CB11). Among Arab-American communities, one community leader noted that smoking rates in public spaces are high among men, while women primarily smoke in their homes, exposing families to second-hand smoke. Hookah smoking in local hookah bars is also prevalent among Arab-American communities. These are culturally-engrained traditions, often marking the status of adulthood or maturity, which are challenging to combat and require culturally appropriate interventions. Additionally, some noted the lack of education and awareness of the importance of preventive health, including not understanding the benefits of seeing primary care physicians and specialists prior to severe illness, how to access primary care, and what services are available. For example, one community leader mentioned that new immigrants often arrive in Brooklyn with no medical records of previous doctor’s visits. Stigma of certain illnesses, including mental health challenges, trauma, and some cancers were seen as barriers to accessing preventive healthcare and screening services. Vaccinations are also less common among certain ethnic and religious groups. Qualitative Component: NYC Department of Health and Mental Hygiene Take Care New York Consultations Take Care New York (TCNY) 2020 is New York City’s blueprint for healthy living, with aims to improve community health and make strides among groups with the worst health outcomes. In the fall of 2015, the DOHMH convened community consultations across NYC and several Brooklyn neighborhoods, during which participants ranked their health concerns and shared suggestions on how to accomplish the TCNY goals. In seeking input from public health officials at the NYC DOHMH, Maimonides consulted with staff at the Brooklyn Neighborhood Health Action Center and also incorporated results from the community consultations. Below are the ranked priority health issues among residents in communities that Maimonides serves.

Bay Ridge Brighton Beach Flatbush Sunset Park

1. Obesity 2. Smoking 3. Air Quality 4. Childcare 5. Drug Overdose

1. Smoking 2. Air Quality 3. Home with no

maintenance issues 4. High blood pressure 5. Obesity

1. Violence 2. Air Quality 3. Home with no

maintenance issues 4. Obesity 5. Unmet medical needs

1. Obesity 2. High school graduation 3. Sugary drinks 4. Smoking 5. Unmet health needs

Source: TCNY Community Consultation Results

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3. Prioritization of Health Needs

In prioritizing the health needs of the community, Maimonides took into account several factors, including their scope/significance; opportunities and estimated effectiveness of possible interventions; the importance the community places on addressing the needs, which Maimonides learned through interviews and the Public Deliberation sessions; existing programs across Maimonides clinical areas and service lines; projects that CCB and the Brooklyn Health Home conduct; as well as alignment with the New York State Prevention Agenda. The primary health concerns that public deliberations participants and key informant interviews cited related to chronic diseases, including diabetes, heart disease and cancer, largely associated with inadequate nutrition and increased obesity rates, lack of regular physical activity, smoking, and high stress levels. These needs mirror the challenges Maimonides sees reflected in its patients. Many patients, including new immigrant communities, do not access primary healthcare routinely, but rather seek care at the hospital for late-stage cancer, heart disease, and other illnesses that are progressed and require tertiary acute care. Furthermore, many immigrant women seeking care at Maimonides have not received prenatal care in their countries of origin, and they often require significant prenatal and maternal and infant care. Lack of health insurance, high out-of-pocket healthcare costs, linguistic and cultural barriers to seeking care, and perceived challenges of accessing care also present significant needs facing our communities, particularly among immigrant communities. It is therefore critical that Maimonides prioritize prevention and early intervention of chronic disease, and enhance access to and utilization of preventive services that are culturally appropriate and tailored to meet the needs of diverse communities. Given the social, linguistic, and financial barriers to good health residents face, MMC is working to enhance access to and utilization of primary and preventive healthcare and facilitate enhanced engagement in healthy behaviors – specifically nutrition, physical activity, and smoking cessation to reduce the risk of developing cardiovascular disease, high blood pressure, diabetes, and some cancers. Selected New York State Prevention Agenda Priorities Based on the community’s measurable health needs, Maimonides’ distinct competencies and resources, and the direct input of community members and partners, Maimonides has elected to focus on the following New York State Department of Health Prevention Agenda priorities:

Prevent Chronic Diseases


Promote Mental Health and Prevent Substance Abuse The PPS and Health Home, and Maimonides in its role with each, is working on all of the above priorities and has additionally prioritized several key health needs, including:

Creating an integrated delivery system and incorporating the full continuum of care to eliminate service fragmentation; prevent avoidable Emergency Room visits and hospital readmissions; and improve chronic disease prevention and disease management

Integrating primary care services and behavioral health, ensuring practices meet Patient Centered Medical Home (PCMH) Level 3 standards, with a focus on care management and integration of behavioral health

Expanding access to community primary care services and equipping community-based and social service organizations with staff and training to meet the individual needs of high-risk patients and provide continuity of care

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Improving access to healthcare services that are culturally and linguistically competent for diverse communities

Increasing early access to and retention in HIV care Selected Health Disparities There are racial, ethnic, and socioeconomic disparities in social determinants of health, healthy behaviors, access to care, and health outcomes among the diverse populations Maimonides serves. For its CSP Maimonides is highlighting the disparity experienced by the Hispanic community with respect to diabetes and obesity. 17% of the residents of MMC’s service area are Hispanic, including 44% of Sunset Park residents. Hispanics experience much greater rates of childhood obesity, diabetes incidence, and diabetes-related mortality than do non-Hispanic Whites.

Examples of Disparities in the Hispanic Population (U.S.) Related to Diabetes and Obesity Statistic Hispanics/Latinos Non-Hispanic White

Age-adjusted percentages of persons 18 years of age and over with diabetes, 2014

12.2% 7.3%

Percentage of obesity among children and adolescents 6-11 years of age, 2011-2014

25.0% 13.6%

Health Needs Not Addressed A number of social determinants adversely affect health in parts or all of Maimonides’ service area. These include air quality, affordability and condition of housing, density of tobacco retailers, accessibility of supermarkets, incarceration, and poverty. While MMC is engaged in work that can affect or compensate for these variables, including as a participant and fiduciary for a DSRIP PPS, as a provider of certain social services, and as an advocate for public policies that promote a healthy Brooklyn, it is not addressing these needs to the degree that it is addressing others highlighted in this document. MMC has chosen to prioritize other needs over these based on the competencies and capabilities it possesses, chief among which are its clinical resources and the relationships it has built across diverse communities and organizations.

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4. Implementation Plan Identification of Resources Potentially Available to Address Health Needs Maimonides commits significant resources to partner with our communities and work to build healthy communities. Maimonides devotes staffing and financial resources to sustain the programs and activities described below in our Implementation Plan, including resources from the following departments:

Patient & Community Relations

Executive Office resources and personnel

Academic Affairs - Residents, Fellows, and the Committee of Interns & Residents

Foundation Grants, with which staff are hired to conduct health interventions

Clinical departments

DSRIP Funding from New York State, which helps to staff the Central Service Organization, which manages and coordinates all DSRIP projects

In alignment with the three priority areas that Maimonides has selected to prioritize – Prevent Chronic Diseases; Promote Healthy Women, Infants and Children; and Promote Mental Health and Prevent Substance Abuse, Maimonides has developed strategies for health promotion and health advancement of its patients and community members on two parallel and often overlapping tracks. On the clinical level, Maimonides is working with the NYC Department of Health and Mental Hygiene to implement services and interventions at the hospital and at outpatient clinical sites, which are predominantly patient-facing, while also developing and implementing community-based programs and initiatives that promote health. Existing and Continuing Programs and Interventions Maimonides has a longstanding history of community engagement and offering culturally diverse and appropriate health education and treatment, which are core to its mission. Beyond providing patient care services, Maimonides is deeply invested in providing service to the greater community, addressing the distinct needs of residents. Since Maimonides conducted its 2013 Community Health Needs Assessment, the hospital has continued its educational and prevention programs and developed additional engagement activities to promote healthy communities and prevent chronic disease, in both clinical and community settings. These programs and interventions will continue over the coming years, and some will be augmented to serve more residents in the service area. Maimonides will continue existing interventions and programs, and will also develop and implement additional community-based strategies to advance health promotion and preventive care. These strategies to foster healthy communities are conducted through:

Education of community members

Preventive care provision, including health screenings, in both clinical and community settings

Training of health professionals

Leading the collaborative efforts among government, community and healthcare provider partners to transform the healthcare delivery system

The programs and interventions that Maimonides currently operates to address community health needs are described below, and include a brief description of the program, intervention/evaluation measures, and partnerships and resources committed to each activity.

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Program Description Intervention Measures /

Planned Impact Resources Committed / Collaboration

Community Health Symposia

MMC Community and Patient Relations Department and clinical leadership lead regular community-based health symposia on heart health, women’s health, diabetes and stroke prevention, and colon, lung and breast cancer awareness events. Our physicians, nurses, and nutritionists provide health education that focus on disease prevention and behavioral modification skills building, that are culturally appropriate and offered in multiple languages.

2016 Impact: 30-40 events 2017-18 Planned impact: 30-40 events annually partnering with community groups targeting heart health, women’s health, diabetes and stroke prevention, and colon, lung and breast cancer awareness.

Resources Committed: Clinical and Community Relations Staff, Promotional and Educational Materials Collaboration: MMC partners with local community- and faith-based organizations, schools, and elected officials to plan, promote, and host the events

Maimonides Commission on Cancer Committee

The MMC Committee for the Commission on Cancer conducts an annual assessment to monitor the effectiveness of prevention, screening and outreach activities based on the needs of the community. They also create and present a Community Health Needs Assessment (CHNA) related to cancer, to determine yearly program goals based on that CHNA data analysis. Each year, the committee facilitates at least one cancer screening program focused on an identified screening need within the community designed to decrease the number of patients with late-stage illness as well as at least one cancer prevention program designed to reduce the incidence of the specified type of cancer. Each year, the Cancer Committee facilitates at least one cancer prevention program that is targeted to meet the needs of the community and is designed to reduce the incidence of a specific cancer type. The prevention program is consistent with evidence-based national guidelines for cancer prevention

Identify prevention and screening needs within the community each calendar year. Decrease the number of diagnoses of a specific cancer type. Modify attitudes and behaviors to reduce the chance of developing cancer. Decrease the number of patients with late-stage disease. Mechanism in place to ensure follow-up for all positive findings consistent with evidence-based national guidelines.

Resources Committed: clinical and Community Relations Staff, Promotional and Educational Materials

Smoking Cessation Program

The Smoking Cessation Program targets communities in South Brooklyn with high rates of smoking and tobacco use. The program educates residents around risk factors of smoking; increases awareness of the importance of early detection; educates patients on risk factors of lung cancer; and provides tools to promote healthy living.

Goal: Decrease the number of patients with late stage disease and attempt to modify behaviors and attitudes for a healthy lifestyle.

Collaboration: Program was developed and implemented using the American Lung Association’s Freedom from Smoking Guidelines, and the Community Relations Department partners with religious institutions, community boards, schools, and senior center to raise awareness

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Breast Cancer Prevention Program

MMC physicians provide community- and clinic-based breast health educational programs that are culturally tailored and appropriate across communities in its service area. The programs aim to: increase awareness about the importance of early detection of breast cancer; educate patients on risk factors; promote the important of annual mammograms; provide self-breast examination tools; and promote healthy lifestyle.

In 2016, approximately 980 women have attended 12 breast health events Communities Targeted/Reached: Asian, Hispanic, Arab, Orthodox Jewish, Haitian, African American and Italian communities Goal: Decrease incidence of breast cancer 2017-18 Planned impact: decrease incidence of breast cancer through prevention, education and screening, with a specific target of teachers in addition to the above mentioned communities.

Resources Committed: clinical and Community Relations Staff, Promotional and Educational Materials, provides breast self-examination tools Collaboration: The Breast Cancer Prevention Program works with community organizations, senior center, religious institutions, and local community boards

Breast Screening Program

The Breast Screening Program targets communities with high rates of breast cancer, including Bay Ridge, Dyker Heights, Bensonhurst, Sunset Park, and Borough Park. The program offers screenings irrespective of ability to pay to women meeting the American Cancer Society’s eligibility criteria. We also provide workshops that discuss the importance of early screening and train women to conduct self-examinations. Through the program, many women receive mammograms, and in cases where breast cancer is found, the women are treated at the Maimonides Breast Center regardless of ability to pay.

Since 2014, 978 women from various communities received a mammogram, from which ten positive cases of breast cancer were found. Goal: Decrease the number of patients with late-stage disease 2017-18 Planned impact: continue to decrease the number of patients with late-stage disease through screening programs targeting various communities including low-income patients with a reduced access to medical services.

Resources Committed: clinical and Community Relations Staff, Arabic language interpreter, Promotional and Educational Materials Collaboration: The Breast Screening Program works with community organizations, senior center, religious institutions, and local community boards

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Prostate Health Awareness Prevention Program

A Prostate Cancer Prevention Program has been developed in 2016 consistent with evidenced-based national guidelines for cancer prevention (American Cancer Society guidelines), targeting the communities and patient populations that have been identified to be at risk in our surrounding areas. The goal is to increase knowledge within the community for the following:

Increase awareness about the importance of early detection

Educate patients on risk factors

Promote the importance of a healthy lifestyle, regular check-up

with a primary physician, and routine blood work

Discuss the tools necessary to lead a healthier lifestyle

To date, MMC has held two educational symposia focused on the Arab-American community in Bay Ridge in addition to one event targeting current members of the NYPD in Boro Park’s 66th Police Precinct. There were a total of approximately 225 attendees. 2017-18 Planned impact: increase awareness of prostate health among men, bringing attention to the fact that Prostate Cancer is the most prevalent form of Cancer among men in our primary and secondary catchment areas.

Collaboration: The Prostate Health Awareness Program works with community organizations, senior center, religious institutions, and local community boards

Colon Cancer Screening Program

Maimonides provides colon cancer screenings to residents regardless of their ability to pay, and promotes awareness and early diagnosis.

In 2016, 30 patients have received free colonoscopies. Of these, 17 patients had adenomatous polyps, 3 patients had polyps, and none were diagnosed with colon cancer. Communities Targeted/Reached: Orthodox Jewish community of Borough Park, Arabic community of Bay Ridge, Italian community of Bensonhurst, 2017-18 Planned impact: continue to promote free colon cancer screening program targeting at risk communities; bring general awareness to Colorectal Cancer and colorectal health.

Resources Committed: Provides screening regardless of patients’ ability to pay; Clinical Personnel Collaboration: Colon Cancer screening provided in collaboration with the NYC DOHMH and the American Cancer Society

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Lung Cancer Screening Program

Established in 2013, the Maimonides Lung Cancer Screening Program eligible residents at high risk of developing lung cancer, regardless of their ability to pay. It uses evidence-based national guidelines for lung cancer prevention (NLST) and offers transportation and language translation to expand accessibility of the programs. The program also offers education and promotes early screening for those at risk of developing lung cancer.

Currently MMC screens an average of 33 patients per month, of whom 85% returned for follow-up appointments as recommended. Goal: Increase in utilization of screening and early detection for lung cancer

Resources Committed: Staff include a lung screening coordinator, skilled radiologists, thoracic surgeons, pulmonologists, and personal navigator and smoking cessation program referrals

Pediatrics Family Advisory Board

The Family Advisory Board is a group comprised of Pediatrics Department clinical staff as well as parents whose children currently receive, or have received, care at MMC. The Advisory Board provides a platform for parents and community members to provide input on how our Pediatrics services and programs can best serve our patients and their families.

Increase communication and feedback between our Pediatrics Department and the communities served

Resources committed: Pediatrics Department staffing, Promotional materials

Chinese Community Health Education and Disease Prevention

Chinese community health education and disease prevention programs include: health education workshops addressing behavioral health, cancer education, heart disease/hypertension/diabetes, pulmonary disease, liver disease, and Hepatitis B; health fairs and screenings, Chinese Cancer Support Group, monthly Chinese Prenatal Education Classes, ongoing Continuing Medical Education dinners for primary care physicians in the Chinese community

The various activities reach over 3,000 community members and primary care physicians annually from the Chinese community.

Resources Committed: Asian Outreach Department and Community and Patient Relations staffing Collaboration: Events are co-organized with community-based organizations

Family Health Challenge

In 2016 MMC implemented the Family Health Challenge (FHC) for the first time in one public school, PS 310 in Brooklyn. The program was developed by the Mary Mitchell Family and Youth Center and the Albert Einstein College of Medicine (AECOM). The FHC is an eight-week, evidence-based overweight and obesity prevention program, during which doctors from the CIR lead weekly sessions and introduce children to a series of healthy behaviors each week.

Increase in healthy eating habits; increase in physical activity; Decrease in obesity among children ages 6-8 years 2017-18 Planned impact: In 2017 MMC will again implement the FHC at one school in Brooklyn

Resources Committed: Program funding, 2-3 resident/fellows staff the lessons each week Collaboration: FHC implemented in partnership with the Committee of Interns & Residents and PS 310

Healthy Living Tips

In response to feedback from the community that residents needed more education and basic understanding of the importance of healthy eating habits and physical activity, MMC developed and launched “Healthy Living: A Step at a Time,” which are weekly healthy living tips and resources that promote nutrition and physical activity for community members of all ages. These tips are distributed via email to community members, elected officials, community groups and partners, as well as staff.

2017-18 Planned impact: Increase Healthy Living Habits, including nutrition and physical activity. Increase the number of people reached per issue from 250 people to 500 people. Integrate content with other community-oriented messaging that MMC is producing.

Resources Committed: Staff to create content

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Building Resilience in Children (BRIC) Program

The Maimonides Departments of Pediatrics and Psychology are the recipients of a grant from the American Academy of Pediatrics to screen children ages 10-18 in outpatient clinics for mental health issues, including anxiety, depression, conduct and behavioral issues, and more. Children with mental health challenges are then offered social work services in a 6-week program. The department also designed and is implementing an educational curriculum for residents and attending physicians to better identify and treat children with behavioral health challenges and train the next generation of general pediatricians. The curriculum with focus on training on Healthy Steps topics, including talking to parents about behavioral health issues among children 0-5, including toilet training, how to feed picky eaters, and more. The purpose of the program is to educate parents of the importance of mental health and destigmatize mental health preventive care.

Over 500 children and adolescents have been screened for mental health problems in one pediatric primary care clinic since mental health screening began in July, 2015; ~20% of those screened had an identified mental health problem, and approximately 40% of patients with a positive mental health screen were referred for co-located mental health services.

Collaboration: The department convenes an advisory board of community-based organizations that provide social services, partnering to refer children to local organizations if/when they do not require direct medical care. BRIC is funded by a 5-year Health Services and Resource Administration (HRSA) grant called Healthy Tomorrows, with assistance from the American Academy of Pediatrics (AAP).

Geriatric Social Services

MMC employs an LMSW to provide family support/education, Mental Health Services to address depression and anxiety, and referrals (e.g. to support groups, assistance with DME, dementia services, managed long-term care services)

The LMSW sees approximately 70 patients per month

Resources: An OMH Grant for Integrated Care has funded this work in the past

Asthma Initiative for Children

As of October 2016, children with persistent asthma will be evaluated for medication competency and compliance as well as identifying asthma triggers in the home through home visits by an asthma educator.

The audience is the population of children with asthma who are referred to allergy/pulmonology for better control. We expect it will be offered to more than 100 children per month.

Resources: This is a DSRIP-funded project Collaboration: This is a partnership with a.i.r.NYC

Traumatic Injury Prevention

As part of its trauma program established August 2016, Maimonides engages in injury prevention activities such as fall prevention education and car seat checks.

To date MMC has conducted six activities reaching 167 community members. Going forward, Evidence-based fall prevention programs are being planned, as well as education for bicycle safety, pedestrian safety, and child passenger (car seat) safety.

Resources: MMC provides an Injury Prevention/Education Outreach Coordinator to organize these activities. Collaboration: MMC works with organizations such as Regional Trauma Advisory Committee, Safe Kids NYC Coalition, New York Traffic Safety Board, NYC Falls Prevention Coalition, Senior Umbrella Network of Brooklyn (SUN-B)

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Women’s Heart to Heart

The Women’s Heart to Heart Program, established in 2013, is an educational setting and social network for women in the community to learn about how to maintain good heart health and to share their experiences with heart disease.

Increase Healthy Living Habits. Over 1,800 women have attended Women’s Heart to Heart events, and approximately 600 have utilized the free heart health screenings offered at the event. Nearly half of the women screened were found to have carotid artery blockage, high blood pressure, or thyroid cancers, which might have otherwise gone undiagnosed until reaching a later and more severe stage of illness. Approximately one quarter of attendees made appointments to see a cardiologist at Maimonides, and several others were referred to other specialists for follow-up care 2017-18 Planned impact: continue to target women at high risk for CVD and provide free health screenings as well as chronic health prevention materials

Resources Committed: clinical and Community Relations Staff, Promotional and Educational Materials, Current contract with Heart Scan Services. Collaboration: Maimonides partners with local community- and faith-based organizations, schools, and elected officials to plan and promote the events

Mended Hearts Support Group

This group provides support and encouragement to heart disease patients and their families. It is a partnership with Mended Hearts, Inc. that facilitates an open discussion forum for Maimonides heart patients to share their medical stories and experiences geared to encourage one another. Clinical staff (including MDs, NPs, NMs, and Dietitians) will be rotated on a monthly basis to present to the Mended Hearts group on an array of health topics including healthy eating, diabetes, lung cancer, CHF, etc.

Information about program is shared with MMC heart patients upon discharge. Support group is available to all those who need/want it. Average turnout is 15 people per meeting.

Mended Hearts provides funding to the Maimonides chapter’s rep to promote the program, create newsletters, etc. MMC funds all catering. Maimonides provides room, speakers, catering, in-house promotion of program.

LVAD Support Group

MMC provides support to patients who have received an LVAD implantation at Maimonides, as well as their caretakers. It hosts a monthly lunch forum by inviting the patients’ doctors, social workers, and other clinical staff to listen to their patients’ (and caretakers) success stories and concerns while encouraging support among patients.

Information about program is shared with MMC LVAD implantation patients upon discharge. Support group is available to all those who want to join. Average turnout is 35 people per meeting.

Maimonides provides room, speakers, in-house promotion of program. The LVAD device vendor provides catering for support group functions.

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NYS-DOH Obesity Prevention in Pediatric Primary Care Settings

MMC was the recipient of a grant (2011-2016) to train primary care pediatricians in the Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity – 2007.

During this period all pediatrics primary care providers, ambulatory staff, and pediatrics residents were trained using specifically designed OSCE (Objective Structured Clinical Exam) case workshops, with reinforcement through on-site mentoring, lectures and web-based sessions. Obesity-related cases were incorporated into all of the OSCE training workshops for Pediatric Resident Training.

NYS-DOH Bureau of Chronic Disease Prevention

Baby-Friendly Practice Certification

A major focus of the NYS-DOH Obesity Prevention Grant was the promotion and support of breastfeeding. Toward this goal and with NYS-DOH support, an assessment was conducted and initial steps were taken toward the Baby-Friendly Practice Certification in the ambulatory setting.

The training and certification of three physician providers as Certified Lactation Consultants, (creating one “Breastfeeding Champion” at each Pediatric Primary Care site), and the creation of a designated Lactation Room at the 7th Avenue Primary Care site. A series of monthly Breastfeeding Education sessions was initiated, rotating through each of the Pediatric Primary Care clinics and the Women’s Health Center.

Resources: MMC provides Pediatrics faculty nurses Collaboration: NYS-DOH Bureau of Chronic Disease Prevention, WIC staff

Vaccination Education

Relative low vaccination rates were identified in MMC’s 2013 CHNA as a disparity affecting the Orthodox Jewish community that MMC serves, as well as affecting other communities in MMC’s service area. MMC has undertaken educational programming geared toward those in the affected communities who have an ability to influence decision-making about childhood vaccination, and vaccination in general.

In May 2016 MMC held an educational event attended by over 40 Rebbetzins. One of the featured topics was a presentation by an MMC Infectious Disease physician about vaccinations.

Resources: MMC provides space, food, and speakers for the events. Collaboration: Informal and formal networks of community leaders promote the events.

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Work Plan for Addressing New York State Prevention Agenda Priorities

Priority Area 1: Prevent Chronic Disease

Focus Area Outcome

Objectives Interventions / Activities Process Measures Partner Role MMC / Partner Resources By When

Increase access to quality chronic disease preventive care and management

Increase screening rates for CVD, diabetes, lung, colon, and breast and cervical cancers

Provide educational health symposia and screenings in Southern Brooklyn particularly addressing chronic disease prevention and management, including a multi-disciplinary focus on women’s heart health, lung cancer screening, colon cancer awareness, diabetes awareness, prostate cancer awareness events in partnership with local community- and faith-based organizations and elected officials

Number of screenings, attendees, and survey cards outlining feedback from events and questionnaire outlining willingness to modify behavior for healthier lifestyle.

Community Groups including NGOs, faith based institutions, and local elected officials serve as event hosts and promoters

MMC provides medical staff, support staff, promotional/collateral items, educational materials, catering, and administrative staff support. Partners provide space and staff to promote events

Goal by year end of 2017 to measure effective-ness

Provide health awareness, screening programs, and prevention for Breast Health. Specifically focusing on partnerships with organizations: United Federation of Teachers (UFT) and Arab-American Association for Bay Ridge.

Number of screenings, attendees, and survey cards outlining feedback from events, and willingness to schedule yearly mammography screening.

Both groups will help recruit event participants and specifically The UFT and Arab American Association will raise awareness of the high rate of breast cancer in MMC’s service area, and within a specific high-risk community.

MMC provides medical staff, support staff, promotional/collateral items, educational materials, catering, and administrative staff support. As well as low cost/ no cost screenings when applicable if attendee meets stated criteria. Also provide materials for breast self- examinations


Provide education health awareness, screening programs, and smoking cessation programming for Lung Health Awareness targeting the Asian American Communities of Sunset Park, Dyker Heights, and Bensonhurst.

Number of screenings and number of smoking cessation participants who quit.

Reach out to Asian American Community Groups and Senior Centers to recruit participants and raise awareness.

MMC provides staff including a lung screening coordinator, radiologists, thoracic surgeons, pulmonologists, personal navigator, and smoking cessation program referrals Community-based groups provide facilities and recruit participants


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Priority Area 1: Prevent Chronic Disease (Cont’d.)

Focus Area Outcome Objectives Interventions / Activities Process Measures Partner Role MMC / Partner Resources By When

Increase access to quality chronic disease preventive care and management

Promote use of evidence-based care to manage chronic diseases

MMC participates in the DSRIP ED Triage project to connect Medicaid beneficiaries who use the ED for non-emergency care to primary care providers who can better manage their care

Number of people connected to PCPs

FQHCs and independent PCPs provide preventive health services

MMC provides patient navigators. MMC clinics, FQHCs and independent primary care practices provide primary care providers.

Already in place – will continue

MMC participates in DSRIP primary care-based initiatives focused on achieving PCMH certification, increasing behavioral health screenings, creating care plans with self-management goals for patients with cardiovascular disease and other chronic conditions, and increasing access to palliative care services and home-based asthma assessments.

PCMH certification, number of screenings for depression and substance abuse, care plans, Integrated Palliative Care Outcome Scale (IPOS), home-based asthma assessments.

PPS member CBOs provide social and other services for patients referred by PCMH-certified practices

PCMH practices work with partner care management agencies and service providers such as a.i.r.NYC to provide services to referred patients


Reduce illness, disability and death related to tobacco use and secondhand smoke exposure

Promote tobacco use cessation, especially among low SES populations and those with poor mental health

The Smoking Cessation Program targets communities in South Brooklyn with high rates of smoking and tobacco use. The program educates residents around risk factors of smoking; increases awareness of the importance of early detection; educates patients on risk factors of lung cancer; and provides tools to promote healthy living.

Number of participants in programs, number of people who indicate they have quit smoking

Community-based organizations promote the program

MMC provides program coordination. Religious institutions, community boards, schools, and senior center to raise awareness


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Focus Area Outcome Objectives Interventions / Activities Process Measures Partner Role MMC / Partner Resources By When

Reduce obesity in children and adults

Prevent childhood obesity through education and programs in early child care and schools

Implemented the Family Health Challenge (FHC) in a public school, PS 310 in Brooklyn. The program was developed by the Mary Mitchell Family and Youth Center and the Albert Einstein College of Medicine (AECOM). The FHC is an eight-week, evidence-based overweight and obesity prevention program, during which doctors from the CIR lead weekly sessions and introduce children to a series of healthy behaviors each week.

Increase in healthy eating habits; increase in physical activity;

The Committee of Interns & Residents is a sponsor. PS 310 is a host

CIR provides 2-3 resident/fellows staff the lessons each week PS310 provides the space and facilitates participation

End of March

MMC conducts school-based workshops, lectures and health fair presentations that focus on healthy eating, obesity and diabetes prevention, and healthy lifestyle modifications for children and parents. These events are culturally-appropriate and offered in multiple languages.

Number of events Number of Attendees

MMC partners with school and PTA staff to plan and promote the events

MMC provides clinical and Community Relations Staff, Promotional and Educational Materials Host organizations provide space and help promote the event

Ongoing through-out the year

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Focus Area

Outcome Objectives Interventions / Activities

Process Measures Partner Role

MMC / Partner Resources By When Address Disparity?

Reduce obesity in children and adults

Expand the role of health care and health service providers and insurers in obesity prevention

MMC is conducting health education in the Hispanic community focused on weight, BMI, healthy eating, and diabetes prevention. It is doing so through a local partnership with United Senior Center of Sunset Park, and through a broader, long-term, bilingual initiative called "¡VIDA SI, DIABETES, NO!"

Number of events (3 in 2016) Number of Attendees (150 in 2016) Rates of awareness of healthy behaviors that reduce the risk of diabetes

United Senior Center of Sunset Park is a host and co-sponsor of health symposia Numerous organizations are supporting "¡VIDA SI, DIABETES, NO!" in various capacities including: American Diabetes Association, Azteca America, Goya Foods, Hispanic Federation, Humana, Lenox Hill Hospital, Maimonides Medical Center, Office Of The Bronx Borough President, Office Of The Brooklyn Borough President, Office Of The Manhattan Borough President, Univision, Union Community Health Center, Wyckoff Heights Medical Center and Telemundo47, American Heart Association, ComunLife, CS55, Fantastico, Latinarrific, and Regional Aid for Interim Needs

MMC provides a registered dietitian and/or a physician to deliver educational material, as well as community relations staff to organize and promote the events United Senior Center of Sunset Park provides space and promotes the events

Ongoing through-out the year

Among children ages two to five in New York, 20.1% of Hispanic children are obese, as compared to 12.4% of Whites.1 Hispanics are almost twice as likely as non-Hispanic whites to be diagnosed with diabetes by a physician, and are 40 percent more likely to die from diabetes than

non-Hispanic whites. 2

1. https://www.health.ny.gov/community/minority/docs/health_issues.pdf 2. U.S. Department of Health and Human Services' Office of Minority Health

https://www.health.ny.gov/community/minority/docs/health_issues.pdf

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Priority Area 2: Promote Healthy Women, Infants and Children

Focus Area Goals Actions & Planned Collaboration Process Measures Partner Role

MMC / Partner Resources

By When

Maternal and Infant Health

Increase the proportion of NYS babies who are breastfed

Maimonides has embarked on the journey to achieve Baby- Friendly Designation, which is awarded to hospitals that support and encourage mother/baby bonding and optimal level of care for infant feeding, aligned with the Ten Steps to Successful Breastfeeding. MMC is currently a part of the NYC DOH Breastfeeding Hospital Collaborative Cohort 3, in which the DOH assists us with resources and guidance on the steps to necessary achieve designation. We are moving towards the Development phase, where we will be developing our Breastfeeding Hospital. MMC is also pursuing baby-friendly practice designation in the ambulatory setting (see p. 33)

NYCDOH is a program sponsor.

NYCDOH breastfeeding collaborative offers us guidance and resources in terms of training, education materials, and access to experts in the field to get us to our goal.

2020

Reduce the rate of maternal deaths in NYS

MMC is on the steering committee for the GNYHA/NYCDOHMH Maternal Depression Quality Collaborative, supported by DSRIP funding. The Collaborative’s goal is universal screening for perinatal depression and appropriate follow up and treatment for women who screen positive. Since August 2016, we have been universally screening our pregnant patients in the MMC women’s clinic using the PHQ-9 (Patient Health Questionnaire – 9) at the first visit, in the 3rd trimester, and postpartum – working together with the Psychiatry department. New EMR will include depression scale PHQ9. This will enable us to perform prenatal and post-partum screening measure reports.

1. % of women screened for depression at their 1st prenatal visit. 2. %of women that screened positive for depression at their 1st prenatal visit. 3. % of women screened positive for depression at their 1st prenatal visit who are then connected to follow up/treatment. 4. % of women screened for depression at a post-partum visit. 5. % of women screened positive for depression at a post-partum visit. 6.% of women screened positive for depression at a post-partum visit connected to follow up/treatment

Psychiatric department and Pediatric department work in collaboration with OBs department. GNYHA/ NYCDOHMH will identify any technical assistance that might be needed to support The Collaborative: Staff Training, Workflow redesign, Data collection

Psychiatry department provides care manager

Ongoing process

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Priority Area 2: Promote Healthy Women, Infants and Children (Cont’d.)

Focus Area Goals Actions & Planned Collaboration Process Measures Partner Role

MMC / Partner Resources

By When

Maternal and Infant Health

Reduce the rate of maternal deaths in NYS

Simulation program for OB residents, OB attendings, and anesthesiology nurses on maternal code, hemorrhage and preeclampsia. Participating with FOJP in safest trial. Labor and Delivery Room initiative - Team Stepps MAVS (Maternal Abnormal Vital Signs) Escalation policy – physicians and nurses are trained to respond to the EMR MAVIS (Maternal Early Warning Signs) system alert and escalation protocols. Build OBS focused EMR with risk assessment protocols for hemorrhage, DVT and MAVIS embedded in the EMR with alert system

Checklist, performance course with feedback for participants

FOJP helps with budgeting – simulation equipment.

EMR vendor works with MMC on obstetrical focused EMR.

Ongoing Ongoing April 2017

Maimonides volunteer doula program, in partnership with N’Shei Cares, offering doula services to any patient at no cost to patient/family, which include services during the prenatal and postpartum periods as well as labor. Planned action for 2017 is to increase number of volunteer Doulas from 64 to 70+.

# of trained volunteer Doulas, # of women served by Doulas

N’Shei Cares is a sponsor and promoter of the program

MMC provides certified training course, mentorship, support

Goal is to have increase number of doulas by June 2017

Child Health

Increase the proportion of NYS children who receive comprehensive well child care in accordance with AAP guidelines

MMC participates in DSRIP initiatives that focus on increasing access to primary care for children, medication adherence for children diagnosed with ADHD, screening for depression in children between the ages of 12-18, asthma home assessment, and medication adherence.

Annual visits to PCP, medication management for ADHD prescriptions, PHQ screenings for depression, home assessment, medication management

Various partner organizations provide support services to patients assigned to MMC through the PPS

MMC and partner organizations both provide health coaches. MMC provides clinical pharmacists. a.i.r.NYC provides asthma community health workers.

Ongoing

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Priority Area 3: Promote Mental Health and Prevent Substance Abuse

Focus Area Goals Actions & Planned Collaboration Process Measures Partner Role MMC / Partner

Resources By When

Prevent Substance Abuse and other MEB Disorders Prevent Substance Abuse and other MEB Disorders

Prevent and reduce occurrences of mental, emotional and behavioral disorders among youth and adults

100 Schools Behavioral Health coach teams will provide assigned schools with coaching, consultation, training and assistance to help them recognize, identify, explore, manage and respond to the mental health and substance abuse needs of the student body. Supported by The Jewish Board and NYAM, the coaches will develop a strong system of community based linkage and referral including behavioral health providers, PPS hospitals and network providers, pediatric practices, Health Homes, community centers, peer support resources, Child Welfare, and Juvenile Justice. They will also act as liaisons between schools/school clusters and the broader provider community. In 2016-2017, the team will begin with 8 schools starting mid-year. In subsequent years, each team will work with 16 schools.

# schools participating, # school staff trained, responses to stakeholder interviews, pre/post-testing

Schools receiving coaching resources and freestanding mental health agency overseeing training of health coaches.

3 health coaches with supervision provided by hospital clinical leaders.

Starting 2nd semester of the 2016-2017 academic year with the program expanding in the following year and beyond.

Middle School Resiliency Curriculum: Psychiatry residents visit local area middle schools to provide mental health education aimed at preventing or diminishing emotional difficulties prevalent within this age cohort. Topics include stress, mind-body connection, deep breathing and stretching techniques for healthy coping. Additional emphasis is placed on identifying available resources to support stress management.

# of visits to schools and patients contacted during visits.

Local area schools serve as program hosts

MMC sets aside resident time from clinical and educational schedules. Local area schools dedicate classroom time for group presentation and discussion.

The program is ongoing and expected to continue in the coming school semester and into the following academic year. The goal is to deliver age-appropriate education targeting 6th grade classes.

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Priority Area 3: Promote Mental Health and Prevent Substance Abuse (Cont’d.)


Resources By When

Strengthen Infra-structure Across Systems

Support collaboration among professionals working in fields of mental, emotional, behavioral health promotion and chronic disease prevention, treatment and recovery

Collaborative Care model is a CCB project in which LCSWs (MMC employees) work as behavioral health care managers in a primary care setting. A consulting psychiatrist backs up the LCSWs

# of practices # depression screenings conducted

Primary care practices

MMC provides LCSWs Primary care practices provide office space

Already in place, will continue

An experienced Licensed Clinical Social Worker with experience and expertise in screening and assessment of referrals for mental health treatment visits teams of primary care, pediatric, and medical specialty providers in the community to educate professionals about signs and symptoms warranting referral, to describe methods of assessment, and to articulate the value of providing coordinated treatment.

Volume of contacts with outside providers.

Partner providers set aside a portion of clinical time to learn about and discuss mental health symptoms and referral practices.

A leading MMC provider sets aside up to 20% of work time to outreach and engagement with community partners.

Ongoing connections with professionals and intent to increase direct contact with community groups.

Maimonides Care Managers provide care management to Medicaid patients with 2+ chronic conditions, Serious Mental Illness, and/or HIV/AIDS as part of Medicaid Health Home and HARP Pilot. Among other component programs, a wellness recovery clinic is used to work with HARP-eligible patients

Patient enrollment and engagement

Multiple MMC provides care managers


Prevent Substance Abuse and Other MEB Disorders

Prevent underage drinking, nonmedical use of prescription drugs by youth, and excessive use of alcohol consumption by adults

Maimonides has adopted an aggressive, structured approach to preventing opioid addiction associated with perioperative and postoperative use of analgesics. As part of MMC’s preoperative universal protocol, before the patient enters the operating room the surgeon and anesthesiologist must confirm that they have held a conversation about a multi-modal, narcotic-sparing pain management plan. Local and regional anesthetic techniques are used in combination with multiple analgesics in smaller doses in order to minimize the use of opioids.

% of time universal protocol is followed

N/A MMC provides all resources to train providers and staff, implement the protocol, and monitor compliance


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Priority Area 3: Promote Mental Health and Prevent Substance Abuse (Cont’d.)


Resources By When

Prevent Substance Abuse and Other MEB Disorders

Prevent underage drinking, nonmedical use of prescription drugs by youth, and excessive use of alcohol consumption by adults

Maimonides will participate in a project organized by the Community Care of Brooklyn (CCB) DSRIP PPS to utilize peer navigators in its ED. These navigators will support ED staff to conduct screening, assessment, and management of opioid use problems. They will also facilitate referrals and linkages with OASAS-licensed opioid treatment providers. In addition to supporting the ED, the navigators will support patients and providers on the inpatient units who meet the relevant criteria.

% of patients who meet criteria who are screened % of patients who meet criteria who are successfully referred to an OASAS-licensed provider Others TBD

MMC will manage staff and implement processes in the ED OASAS-licensed treatment providers will receive referred patients. CCB will provide overarching program design and funding, and help create closer linkages between hospitals and opioid treatment providers

CCB will fund peer navigators MMC will provide existing ED personnel who will conduct screenings

Program will be implemented by the end of 2017

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5. Ongoing Engagement with Partners and Communities Served Maimonides will continue to work closely with the people it serves, the formal and informal leaders who represent its communities, and a range of organizations that provide complementary services. It will do so via the many programmatic partnerships described in the implementation plan found in Section 4 above. In addition, MMC will report to the community and obtain input on its programming via regularly scheduled meetings of the Maimonides Council of Community Organizations (COCO) and through an expanded structure of Patient and Family Partnership Councils (PFPC) organized around specific clinical conditions and services.

6. Dissemination and Awareness of the CHNA/CSP The principal method of distributing the CHNA/CSP will be via Maimonides’ website at www.maimonidesmed.org. Maimonides will promote awareness of the document’s availability on its website via announcements, emails, and other written communications associated with its many programs and meetings that involve members of the community. A paper copy of the CHNA/CSP will be made available for inspection at Maimonides upon request.

http://www.maimonidesmed.org/

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Appendix A: Key Sources for Quantitative Data Found in the CHNA/CSP

Data Set Source Information How Used

MMC Inpatient Demographic Data

MMC Finance

Geographic origin (zip code) and race/ethnicity of patients served

Define community

Community Health Profiles

NYC DOHMH Demographics of communities, health outcomes (e.g. diabetes, obesity, stroke hospitalization, screening, etc.), healthcare access, poverty/education levels, health behaviors

Define health needs

Epiquery Community Health Surveys

NYC DOHMH Health outcomes (high BP, cholesterol, diabetes, obesity, etc.) updated annually

Define health needs, trends over time

Cancer Incidence / Prevalence

NYS Cancer Registry

Cancer rates by neighborhood and type

Define health needs

Take Care New York 2020 Community Consultations

NYC DOHMH Top 5 health issues ranked by community members during DOHMH community consultations

Define health needs

NYS Prevention Agenda NYS DOH Priority health issues defined by the State

Prioritize health needs, implementation plan

New York City Health Provider Partnership Brooklyn Community Needs Assessment (DSRIP can)

CCB Website Health needs and outcomes for Brooklyn

Define health needs across Brooklyn, with a focus on Medicaid population

https://www1.nyc.gov/site/doh/data/data-publications/profiles.page#bk

https://www1.nyc.gov/site/doh/data/data-publications/profiles.page#bk

https://a816-healthpsi.nyc.gov/epiquery/CHS/CHSXIndex.html

https://a816-healthpsi.nyc.gov/epiquery/CHS/CHSXIndex.html

https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/tracking_indicators.htm

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Appendix B: Maimonides Community Health Internal Coordinating Committee Roster

Name Title

Alexander Alvarez VP, Care Management

Gabrielle Gaspard Director of Research

Robin Gitman VP, Academic Affairs

Dina Gramegna Clinical Director, Employee Health Services

Shoshana Haberman, MD Director, Maternal and Fetal Medicine

Charles Hartley Network Development Specialist

Douglas Jablon SVP, Patient Relations

Ruth Knecht Nurse Manager, Cancer Center

Alejandro Lojo Project Manager, Heart & Vascular Institute

Barbara Lowell, RD Pediatric Nutritionist & Coordinator, NYS-OPPHCS Grant on nutrition education & training

Julie Morgan, MD Director, Ambulatory Services

Gia Ramsey Trauma Injury Prevention/Education Outreach Coordinator

Raymond Riley Events Coordinator, Patient/Community Relations

Ravi Saksena, MD Attending Pediatric Physician

Eric Scalettar SVP, Strategic Planning

Adam Stolz VP & Chief of Staff

Shari Suchoff VP, Population Health Policy & Strategy

Patricia Ursomanno Program Director, Heart & Vascular Institute

Bina Valenzano Administrative Manager, Patient Relations

Maimonides Medical Center Community Health Needs … CHNA-CSP... · 2016-12-30 · Maimonides...

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