Wyckoff Heights Medical Center Community Service Plan, 2017-2020
WYCKOFF HEIGHTS MEDICAL CENTER
Community Health Needs Assessment and Community Service Plan
2017-2020
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF HOSPITAL & PRIMARY CARE SERVICES COMMUNITY SERVICE PLAN CONTACT INFORMATION SHEET
Name of Facility: Wyckoff Heights Medical Center Address: 374 Stockholm Street City: Brooklyn, NY 11237 County: Kings DOH Area Office: New York Metropolitan Regional Office (NYC Area 90 Church Street, 15th floor, New York, NY 10007) Hospital Program Fax # (212) 417-5914
CSP Contact Person (s): Zachariah Hennessey, MA Title: Assistant Vice President, Special Projects and Evaluation Phone: 718-907-4952 Fax: 718-963-7719 E-mail: [email protected]
CEO/Administrator: Ramón J. Rodriguez Title: President / CEO Phone: 718-963-7101 Fax: 718-963-7196 E-mail: [email protected]
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
Wyckoff Heights Medical Center Service Area Heat Map Zip Codes and Percent of Unique Patients Served
Zip Codes Neighborhoods (% Patients) Primary Service Area 11237 (22%) Bushwick >75% of patients 11385 (17%) Ridgewood reside here 11221 (16%) Bedford Stuyvesant 11207 (9%) East New York 11206 (6%) Williamsburg 11208 (6%) East New York Secondary Service 11233 (3%) Bedford Stuyvesant Area 11212 (3%) Brownsville >10% of patients 11211 (2%) Williamsburg/Greenpoint reside here 11378 (1%) Maspeth 11421 (1%) Woodhaven 11379 (1%) Middle Village
Percent of Unduplicated Patients Served, 2015
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
Table of Contents
INTRODUCTION ...... 5 Wyckoff Heights Medical Center History and Scope of Services ...... 6 Mission Statement and Community Vision ...... 7 Hospital Service Area ...... 9 COMMUNITY HEALTH NEEDS ASSESSMENT ...... 13 Overview ...... 13 Chronic Diseases ...... 14 Environment ...... 15 Women, Infants and Children ...... 15 Mental Health and Substance Use ...... 16 Human Immunodeficiency Virus (HIV), Sexually Transmitted Infections (STI), Vaccine-Preventable Diseases (VPD), and Healthcare-Associated Infections (HAI) ...... 17 Community Input and Prioritization Process ...... 20 Partnerships ...... 22 ADDRESSING PREVENTION AGENDA FOCUS AREAS ...... 26 Preventing Chronic Diseases...... 26 Promoting a Healthy and Safe Environment ...... 27 Promoting Healthy Women, Infants and Children ...... 28 Promoting Mental Health and Preventing Substance Abuse ...... 31 Preventing HIV, Sexually Transmitted Infections, Vaccine-Preventable Diseases, and Healthcare-Associated Infections ...... 32 THREE YEAR COMMUNITY SERVICE PLAN ...... 35 FINANCIAL PROGRAM ...... 38 DISSEMINATING THE PLAN ...... 39
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
INTRODUCTION Plan, including the Prevention Agenda 2013- In the wake of the Affordable Care Act (ACA), 2017. This plan aims to make New York the healthcare is undergoing a major healthiest state in the nation. transformation. The ACA has charged healthcare providers with restructuring the More locally, New York City’s Take Care New service delivery system to better support York (TCNY) 2020 is the City’s blueprint for preventive care that meets the holistic health giving all residents the chance to live a healthier needs of individuals, families and communities. life. TCNY has two goals — to improve every This transformation is grounded in guiding community’s health, and to make greater principles such as Patient-Centered and Whole- strides in groups with the worst health Person Care, and is embodied in emerging outcomes, so that the city becomes a more models such as the Accountable Care equitable place for everyone. Unlike previous Organization and the Patient-Centered Medical Take Care New York plans, TCNY 2020 looks at Home. New payment methodologies are being social factors in addition to traditional health rapidly implemented to finance the transition factors, such as how many people in a from a volume-based to a value-based system community graduate from high school or go to of reimbursement. jail.
This healthcare transformation is being driven It is against this backdrop that Wyckoff Heights by policy initiatives on the national, state, and Medical Center prepared this Comprehensive local levels. On the national front, the U.S. Community Service Plan (CSP). These global, Department of Health and Human Services national and local community health initiative, Healthy People 2020 (HP 2020), improvement initiatives informed Wyckoff’s envisions a society in which all people live long, CSP and provided the impetus for addressing healthy lives. HP 2020 is the result of a and meeting the most pressing health care multiyear process that reflects input from a needs in the diverse communities we serve. In diverse group of individuals and organizations order to be effective in this effort, we must and provides science-based, 10-year national increasingly collaborate with the community objectives for improving the health of all and extend beyond our walls to address the Americans. Its aims are to help people live high- non-medical structural, cultural, and social quality, longer lives free of preventable disease, determinants of health specific to the disability, injury, and premature death; to neighborhoods we serve. To better understand improve health equity and reduce disparities; our population, we have systematically and to create social and physical environments evaluated the prevention service needs and that promote good health across all life stages. priorities of the local community. And through collaborative, cross-sector strategic planning, in At the State level, New York has launched partnership with residents and local initiatives such as the Health Home Program, stakeholders, we have developed a plan of Delivery System Reform Incentive Payment services that will help people achieve and Program (DSRIP), and the Vital Access/Safety sustain good health. Net Provider Program. These programs have been designed to help to reorganize service There have been numerous studies in recent delivery with the aim of improving coordination years focused on community and population of care, reducing avoidable hospitalizations, and health and the healthcare delivery system in reducing the use of Emergency Departments for Brooklyn, the most recent of these being primary care sensitive conditions. The State also Northwell Health’s “The Brooklyn Study: has been implementing its Health Improvement Reshaping the Future of Healthcare.” This report recommends developing a “Health
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
Enterprise Zone” and a regional “division of community service projects to address a broad community health and engagement” to provide range of health-related concerns. infrastructure and resources to better integrate clinical care with a coordinated continuum of Wyckoff Heights Medical Center operates a 24- programs addressing the social determinants of hour New York City 911 receiving hospital health.1 This community service plan clearly emergency department, with an area devoted describes Wyckoff’s current alignment with this to pediatrics. The medical center is a New York strategy and collaborative approach to State designated stroke center and level III addressing social determinants of health in perinatal center. The American Heart Brooklyn and Queens over the next three years. Association and the American Stroke Association have awarded the hospital with a "Gold Plus Performance Achievement Award" Wyckoff Heights Medical Center every year since 2012. Today, Wyckoff provides History and Scope of Services 90,000 visits annually in our Pediatric/Adult Emergency Departments, delivers 1,400 babies, Founded in 1889 as the German Hospital of and offers outpatient services to thousands at Brooklyn, Wyckoff Heights Medical Center our network of community ambulatory care (Wyckoff) has been providing care to the centers. residents of Brooklyn and Queens for more than 125 years. Located in an ethnically diverse Quality patient care is dedicated team effort. At residential neighborhood, Wyckoff is a 374-bed, Wyckoff, we have created a warm, caring place voluntary, teaching hospital. A dedicated staff for healing. Patients who receive care at of nearly 1,900 physicians, nurses and support Wyckoff observe extraordinary cooperation personnel care for patients of thirty-five distinct between the Hospital's clinical and non-clinical languages and cultures. personnel. While physicians, nurses and other healthcare professionals oversee the medical Wyckoff is a not-for-profit, safety-net management of patients, non-clinical staff community hospital providing medical care in a ensure that their holistic needs are being met. region that is experiencing some of the most Furthermore, the Hospital's ecumenical significant economic, social and health Chaplaincy Program provides for the spiritual inequities in New York City. At a time when needs of our patients and their families, and for many hospitals are experiencing significant those who so desire, the Hospital's chapel is reductions in resources and services, Wyckoff open 24 hours a day for meditation and continues to respond to the growing healthcare worship. needs of the communities we serve by expanding and enhancing clinical programs. To ensure we meet the future healthcare needs Recent improvements include developing and of the communities we serve, Wyckoff growing community-based ambulatory care undertakes the responsibility of training new sites including the Wyckoff Medical Arts Center, generations of qualified physicians through our the Wyckoff Pediatric Care Center, the residency programs. Wyckoff offers Residency Women's Health Center, and a new Wyckoff programs in Internal Medicine, Obstetrics and Doctors Practice. In the outpatient setting, Gynecology, Pediatrics, Surgery, Wyckoff has established innovative new Anesthesiology, Dentistry, Pediatric Dentistry, community health engagement and and Podiatry. Curricula include patient care, improvement initiatives through a variety of didactic lectures, skilled workshops, on-line modules, journal club, performance improvement and scholarship. Residents have 1https://www.northwell.edu/sites/northwell/files/20830- Brooklyn-Healthcare-Transformation-Study_0.pdf the opportunity to care for acutely-ill,
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020 chronically-ill and healthy adults and children of per capita cost of care for the benefit of all ages. Residents have opportunities to communities. enhance knowledge, skills, and communication strategies in order to provide safe and effective Wyckoff Heights Medical Center’s mission and care in cooperation with a healthcare team. goals will be achieved through the following They assume progressive responsibility objectives: throughout training, with the goal of becoming The Medical Center will provide the independent practitioners. highest level of care for all patients regardless of their ethnic origin, race, Wyckoff also operates a comprehensive creed, color, national origin, sex, continuing medical education (CME) program physical disabilities, sexual orientation, accredited by the Medical Society of the State or ability to pay. The worth and dignity of New York. The CME program is designed to for each individual will be recognized. meet the needs of the medical staff and The Medical Center will improve the community-based physicians in maintaining a health status of the community by contemporary base of scientific knowledge actively participating in organized, appropriate to their regular professional innovative system transformation, with activities. The CME program makes available a a focus on value. sufficient volume of presentations in all The Medical Center will promote and disciplines by reputable specialists, which support all efforts to provide a safe provide ample opportunities for physicians to environment for our patients, advance their knowledge and clinical skills so employees and visitors. that they may continually enhance the quality of patient care. Teaching methods are tailored Community outreach and engagement is critical to the specific needs of the medical staff and to achieving these goals. Together with more community based physicians and include than 30 community partner representatives, didactic lectures, clinical case studies, live Wyckoff developed the following vision for the demonstrations, hands on participatory health of the North-Central Brooklyn and South workshops, and self-directed learning in the Queens region: medical library using text, audiovisual and computer-assisted instruction. “Our vision of a healthy community is a place where people want to live, work and play. It is a supportive and connected environment where Mission Statement and Community diverse people work together for the common Vision good. All people here, regardless of their differences, have access to the necessities of “Wyckoff Heights Medical Center is committed life. In this community, people across the to providing a single standard of highest quality lifespan enjoy recreational activities, safe care to our community through prevention, streets and play areas, healthy food, and quality education and treatment in a safe education and healthcare. Trustworthy environment.” systems foster kindness, equality, fairness and generosity. Public and private interests work Wyckoff’s mantra is to provide care, with together, respect the value of people, and are kindness and respect. Wyckoff is committed to continuously improving. achieving the triple aim of improving the health of our population, enhancing the experience Over the next three years, we want to see and outcomes of our patients, and reducing the transformational outcomes for our community, through increased services and access for a
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020 growing population. By forming a well- connected network of service providers and community supports, we will expand preventive and behavioral health services, and our community will become more knowledgeable and healthy, and will live longer, more joyful lives.
To get there, we will form true partnerships that collaborate effectively, sharing responsibility, financial resources, data systems and infrastructure. We will need to trust one another, be open to change, generous, and committed to following-through. Diverse teams will engage in open and transparent change management that is informed, thoughtful, process-oriented, and supported by leadership. This is our vision for the system of care in North- Central Brooklyn and South Queens.”
The Community Service Plan has been developed to support this picture of the future, which provides guiding principles and a framework for evaluating our success between now and 2020.
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
Hospital Service Area Wyckoff is a full service community hospital serving culturally diverse populations in the counties of Kings and Queens. To define our service area, we analyzed unique patients served in 2015 by zip code of residence. The area where more than 75% of individual patients reside is defined as Wyckoff’s primary service area, and the area where the next 10% of patients reside is termed the secondary service area. The two together will be referred to as the “Hospital Service Area.” The following table summarizes the zip code data and defines the primary and secondary service areas:
Figure 1: Wyckoff Heights Medical Center Hospital Service Area
Zip Codes Neighborhoods (% Patients) Primary 11237 (22%) Bushwick Service Area 11385 (17%) Ridgewood >75% of 11221 (16%) Bedford Stuyvesant patients reside 11207 (9%) East New York here 11206 (6%) Williamsburg 11208 (6%) East New York Secondary 11233 (3%) Bedford Stuyvesant Service Area 11212 (3%) Brownsville >10% of 11211 (2%) Williamsburg/Greenpoint patients reside 11378 (1%) Maspeth here 11421 (1%) Woodhaven 11379 (1%) Middle Village
Wyckoff is located on the border of Bushwick, Brooklyn and Ridgewood, Queens. Our service area is one of the most ethnically and culturally diverse constituencies in New York City. It includes the neighborhoods of Bushwick, Bedford Stuyvesant, East New York, Williamsburg and Brownsville in Brooklyn, as well as Ridgewood, Maspeth, Woodhaven, and Middle Village in Queens. The Hospital’s Service Area is home to over one million persons and is extremely diverse in age, racial and ethnic identity, culture, language, and country of origin.
Nearly a quarter of all Wyckoff patients reside in Bushwick, Brooklyn. Neighborhoods in New York do not have official boundaries, but the boundaries of Bushwick are approximately those of Brooklyn Community District 4 (BCD4). Sixty-five percent of BCD4’s 114,134 residents identify as Hispanic or Latino, making Bushwick the largest hub of Brooklyn’s Hispanic-American community.2 The other racial/ethnic groups include Blacks/African Americans (20%), Whites (9%), Asians (4%), and others (2%). It is important to note that 33% of Bushwick residents have limited English language proficiency, making linguistic competence, particularly in Spanish, crucial to the success of Wyckoff’s community service plan.3 Bushwick’s array of immigrant groups whose language, culture, religious affiliations, and other mores create a rich vibrancy to the community.
Approximately 19% of Wyckoff’s patient population reside in three zip codes that make up Brooklyn Community District 3 (BCD3), which roughly corresponds to the neighborhood of Bedford-Stuyvesant, or
2 Table PL-P3A NTA: Total Population by Mutually Exclusive Race and Hispanic Origin - New York City Neighborhood Tabulation Areas, 2010, Population Division - New York City Department of City Planning, March 29, 2011. Accessed June 14, 2016. 3 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015.
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020
“Bed-Stuy.” For decades, Bed-Stuy has been a cultural center for Brooklyn's African American population. Beginning in the 2000s, the neighborhood began to become increasingly racially, economically, and ethnically diverse, with an increase of foreign-born Afro-Caribbean and African residents as well as residents of other ethnic backgrounds. As a result, Bed-Stuy is the neighborhood in Brooklyn with the highest proportion of residents who are foreign born.4 Bed-Stuy is undergoing a process of gentrification, with an influx of new residents contributing to the displacement of poorer residents.5 Of Bed-Stuy’s 154,332 residents in 2014, 64% were Black/African American, 20% were Hispanic/Latino, 11% were White, 2% were Asian/Pacific Islander, and 2% reported other ethnicity.6
Seventeen percent (17%) of Wyckoff’s patients resides in Queens Community District 5 (QCD5) including Ridgewood, Glendale, Maspeth and Middle Village in Queens. In the early 20th century, Ridgewood attracted Germans, Italians and other European immigrants who found refuge from Manhattan’s crowded tenements in its spacious brick and stone townhouses. More recently, immigrants from Albania and Poland settled there, along with those from the Caribbean, Mexico and Latin America. The NYC Department of Planning’s 2013 report on immigration trends, reported persons from Poland as the largest immigrant group in Ridgewood, followed by smaller numbers of Ecuadorians, Dominicans and Mexicans. As of 2014, QCD5 was home to 169,734 persons: 54% identified as White, 36% as Hispanic/Latino, 8% as Asian/Pacific Islander, 1% as Black, and 1% as other. Twenty-three percent of residents of QCD5 have limited English language proficiency.7 In addition to Spanish, Polish and Russian are important language competencies at Wyckoff. Wyckoff also serves key subpopulations residing in parts of Queens Community Districts 6 and 9 (QCD6, QCD9), particularly seniors residing in the neighborhood of Woodhaven. Woodhaven is a mostly residential and semi-suburban neighborhood with a low-density population, consisting mostly of European and Hispanic Americans, a small number of African Americans, and a growing number of Asian Americans.
Approximately 15% of Wyckoff’s service population reside in the East New York zip codes 11207 and 11208. East New York is an under-resourced residential neighborhood in the eastern section of the borough of Brooklyn, represented by Brooklyn Community District 5 (BCD5). During the latter part of the twentieth century, East New York came to be predominantly inhabited by African Americans and Latinos who migrated to the region in search of employment. Unfortunately, many of the manufacturing jobs they sought were leaving NYC during this wave of immigration, leaving many in the area without good employment prospects. Many social challenges associated with poverty from crime to drug addiction have been prevalent in the area for decades.
Approximately 8% of Wyckoff’s population reside in the neighborhoods of Williamsburg and Greenpoint, which constitute Brooklyn Community District 1 (BCD1). Williamsburg is an influential hub of contemporary music, with a large local hipster culture, a strong art community and vibrant nightlife. The area experiences a steady gentrification. Many ethnic groups have based enclaves within the neighborhood, including Italians, Jews, Hispanics, Poles, Puerto Ricans and Dominicans. Greenpoint is the northernmost neighborhood in the New York City borough of Brooklyn. It has a large Polish immigrant and Polish-American community. As with Williamsburg, the recent and continuing building boom in the neighborhood, especially of multifamily dwellings, among other demographic changes, has
4 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 5 Echanove, Matias. "Bed-Stuy on the Move". Master thesis. Urban Planning Program. Columbia University. Urbanology.org. 2003. 6 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 7 Ibid.
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Wyckoff Heights Medical Center Community Service Plan, 2017-2020 led to a process of gentrification. Collectively, Williamsburg and Greenpoint are home to 176,937 residents, who are 61% White, 27% Hispanic, 6% Asian, 5% Black, and 1% Other Race.8
The following table summarizes key demographics of Wyckoff’s Primary Service Area:
Table 1: Wyckoff primary service area (PSA) population, race/ethnicity, and English proficiency9 Other Limited Neighborhood Total Pop Black Hispanic White Asian Race English Bushwick 114,134 20% 65%* 9% 5% 1% 33% Ridgewood, Glendale, Maspeth, Middle Village 169,734 1% 36% 54%* 8% 1% 23% Bedford Stuyvesant 154,322 64%* 20% 11% 2% 2% 13% East New York 183,971 52%* 37% 3% 6% 2% 16% Williamsburg/Greenpoint 176,937 5% 27% 61%* 6% 1% 24% Total PSA 799,098 29% 35% 29% 6% 1% 21% *Indicates highest proportion in each neighborhood
Wyckoff’s service area is characterized by extreme socioeconomic inequities. There are stark contrasts between the neighborhoods where the majority of residents are white (Williamsburg/Greenpoint and Ridgewood), and those where the majority of residents identify as Hispanic or Black (Bushwick, East New York, and Bedford Stuyvesant). For example, in Bushwick, where Wyckoff is located, 42% of the population has less than a high school education, whereas just next door in Williamsburg/Greenpoint, the rate is only 17%. Likewise, more than 30% of Bushwick’s residents are living below federal poverty level, while in neighboring Ridgewood, the rate is only 14%. Bedford Stuyvesant has one of the highest rates of jail incarceration in New York City, at 244 per 100,000 persons, a rate more than six times that of Ridgewood, at 38 per 100,000. The following table summarizes these characteristics:
Table 2: Wyckoff primary service area (PSA) socioeconomic characteristics10 Total Bushwick and its surrounding Brooklyn neighborhoods constitute a Department of Health and Human Services designated Medically Underserved Area and are part of the Brooklyn Public Health District, one of three areas identified by NYC with the highest rates of health disparities and poor healthcare access. The region of Northern-Central Brooklyn accounts for the greatest proportion of patients without insurance, the largest numbers of preventable hospital admissions and the most potentially preventable emergency room visits in the borough. At the same time, this region is a Health Professional Shortage Area (HPSA) with sparse numbers of primary care and behavioral healthcare providers.11 8 Ibid. 9 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 10 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 11 New York Academy of Medicine: New York City Health Provider Partnership Brooklyn Community Needs Assessment. October 3, 2014. 11 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Because of these gaps in healthcare services, Wyckoff is an essential healthcare provider for our service area. Seventy-six percent of Wyckoff’s patients are insured by public insurance or are uninsured, which designates the medical center a safety-net hospital: Table 3: Wyckoff’s safety net population Insurance Total Pop Percent Medicaid/Medicaid Managed Care 41,695 50.9% Medicare/Medicare Managed Care 11,030 13.5% Uninsured/Self-Pay 9,469 11.6% Insured 19,689 24.0% Total 81,883 100.0% The services Wyckoff provides are crucial to addressing unmet medical need in the service area. In 2015, Wyckoff discharged 13,875 patients, including 1,437 births, and provided over 136,950 outpatient visits. Additionally, some 88,428 were seen in the adult and pediatric emergency department. The following service utilization data from 2012-2016 shows changes reflective of Wyckoff’s commitment to healthcare delivery system reform, with decreasing numbers of annual inpatient discharges, and rapidly growing outpatient services: Table 4: 2012-2016 inpatient discharges, deliveries, emergency department visits, and clinic visits Service Year 2012 2013 2014 2015 2016 (6 months) Annual Discharges 18,777 15,841 14,970 13,875 6,867 Babies Delivered 1,873 1,614 1,532 1,437 749 Emergency Room Visits 88,286 87,411 89,761 88,428 45,134 Clinic Visits 105,227 107,072 118,591 136,950 72,944 12 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 COMMUNITY HEALTH NEEDS ASSESSMENT Under the Affordable Care Act (ACA), hospitals are required to conduct community health needs assessments to determine local health priorities and to adopt strategies that foster improvements in community health. The New York State Department of Health (NYS-DOH) has a similar mandate for its Prevention Agenda. In keeping with both requirements, Wyckoff Heights Medical Center (Wyckoff) has organized its Community Health Needs Assessment according to the NYS Prevention Agenda focus areas: 1) preventing chronic diseases; 2) promoting a healthy and safe environment; 3) promoting healthy women, infants and children; 4) promoting mental health and preventing substance abuse; and 5) preventing HIV, Sexually Transmitted Infections, vaccine-preventable diseases, and healthcare- associated infections. Methods. The Community Health Needs Assessment methods included literature review, analysis of public health data sets, analysis of hospital service utilization and electronic medical record data, input from community leaders, and a community health prioritization survey of both local residents and stakeholders. Wyckoff also collaborated with the New York City Department of Health and Mental Hygiene (NYC-DOHMH) through their Take Care New York assessment of needs and prioritization process. To build momentum toward TCNY 2020 goals, NYC-DOHMH held dozens of Community Consultations across the city during fall and winter of 2015-2016. At these public events, facilitators asked community members to share what issues they see as most urgent in their neighborhoods. More than 1,000 New York City residents participated in this process. Wyckoff’s Community Health Needs Assessment links community health survey results and community consultation findings to prevention agenda focus areas, and incorporates them into a three-year service plan. Overview There are significant challenges to improving population health and the healthcare system in Northern and Central Brooklyn. Unmet health need is indicated by rates of chronic disease, premature mortality and avoidable Emergency Department visits and hospitalizations that are far greater here than in the rest of Brooklyn, NYC, the State and the Nation. Premature mortality is as high as 330 per 100,000 population in Bedford-Stuyvesant, compared with 198 per 100,000 in NYC overall.12 In addition, there is a shortage of quality, accessible primary care coupled with challenges to full utilization of existing primary care providers.13 Wyckoff’s Emergency Department diagnostic data reflects these unmet health needs, with the most frequent diagnoses including Upper Respiratory Infection, Asthma, Gastroenteritis, Ear and Urinary Tract Infections, and Viral Infections. A large proportion of these visits could most likely be prevented with accessible and effective primary care. Demographic data indicates that the healthcare system in the area will become even more strained. The service area has a population that is growing more rapidly than other regions in NYC, and is experiencing increasing demand for primary care from the aging population, which grew 19% from 2000-2010 and is projected to grow rapidly by 2020, with the age 65-74 to increase by 23% and the population 75 and older to increase by 19%.14 The region also has an extremely high birth rate relative to other parts of Brooklyn and NYC.15 In addition, the largest proportion of Wyckoff’s patient population consists of publicly insured (Medicaid, Medicare, Medicaid Managed Care) individuals residing in Northern-Central 12 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 13 Brooklyn Healthcare Improvement Project: Final Report: Making the Connection to Care in Northern and Central Brooklyn. August 8, 2012. 14 U.S. Census data and projections. 15 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 13 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Brooklyn. Regression analysis of this population’s data from the New York State Department of Health (NYS-DOH) Statewide Planning and Research Cooperative System (SPARCS) found that Medicare and Medicaid covered individuals were more likely to have an Emergency Department visit for an ambulatory care sensitive condition compared to those with commercial insurance. Analysis also showed that the odds of having an ambulatory care sensitive condition admission to the hospital were higher for blacks and Hispanics than for whites. Residing in a census tract with the lowest quartile of median income, highest rates of those without at least a high school education, highest vacant housing rates, and highest rates of those who speak limited English were all associated with higher odds of visiting the Emergency Department for non-emergent care.16 For these reasons, Wyckoff’s Community Service Plan has been developed in alignment with regional processes for healthcare delivery system transformation. This transformation will address non-medical determinants of health through more accessible, community-based, preventive care. Chronic Diseases Wyckoff’s service area is profoundly affected by high rates of Chronic Diseases and their developmental antecedents: The rate of Stroke in Bushwick is 47% higher than the NYC overall rate. The rate of child asthma hospitalization in Bushwick is more than double that of NYC. 37% of Bushwick residents consume one or more sugary beverage per day. In Bedford-Stuyvesant and Bushwick, rates of obesity are 33% and 28% respectively, compared to 24% in NYC overall. Diabetes rates are extremely high in East New York, Bedford-Stuyvesant and Bushwick, disproportionately affecting persons of Latino/a ethnicity. Between some neighborhoods in the service area, there are stark contrasts. For example, the rate of hospitalization for stroke in Bushwick is 470 per 100,000 population, whereas just next door in Williamsburg, the rate is only 293 per 100,000. Likewise, Bushwick’s childhood asthma hospitalization rate is 70 per 10,000 children, compared to neighbors Williamsburg and Ridgewood, which have a rate of 18 per 10,000 children; and Bushwick’s Diabetes hospitalization rate is more than double that of Williamsburg. These data suggest targeted approaches to preventive intervention. The following table summarizes indicators of chronic diseases and their antecedents in Wyckoff’s service area: Table 5: Chronic diseases and associated antecedents in Wyckoff’s service area17 Child Heart Stroke Physical Asthma Deaths Neighborhood Smoking Soda Obesity Diabetes (per Activity (per (Per 100,000) 10,000) 100,000) Bushwick 16% 37%* 74% 28% 13% 470* 70* 210.7 Ridgewood, Glendale, 16% 27% 77% 21% 7% 259 18 202.5 Maspeth, Middle Village Bedford Stuyvesant 20%* 34% 76% 33%* 15% 415 54 267.8* East New York 17% 34% 73%* 31% 18%* 414 50 223.1 Williamsburg/Greenpoint 20%* 21% 76% 24% 10% 293 18 211.3 NYC 15% 27% 77% 24% 10% 319 36 202.6 * Indicates highest or lowest rate in the service area 16 Brooklyn Healthcare Improvement Project: Final Report: Making the Connection to Care in Northern and Central Brooklyn. August 8, 2012. 17 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 14 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Environment The environmental conditions of Wyckoff’s neighborhoods contribute to disparate health outcomes. Environmental determinants of health reflect the physical conditions of the environment in which people are born, live, learn, play, work, and age. They impact a wide range of health, functioning, and quality-of-life outcomes. Key indicators related to environmental health in Wyckoff’s service area include violence, housing quality, air pollution, tobacco retailer density, and supermarket square footage. The area is particularly impacted by violence, with non-fatal assault hospitalizations occurring twice as frequently as in New York City overall. The table below summarizes environmental conditions in the service area: Table 6: Environmental conditions in the Wyckoff service area18 Neighborhood Housing Defects Air Pollution Tobacco Retailers Supermarket Area Violence Bushwick 73%* 8.8 0.0016* 1.0* 0.00091 Ridgewood, Glendale, 50% 8.8 0.0014 2.5 0.00022 Maspeth, Middle Village Bedford Stuyvesant 67% 8.8 0.0016* 1.2 0.00129* East New York 70% 8.7 0.0013 1.8 0.00120 Williamsburg/Greenpoint 54% 10.1* 0.0014 1.5 0.00043 * Indicates highest rate in the service area Women, Infants and Children Perinatal Health. Between 2012 and 2014, there were 28,193 births in Wyckoff’s service area zip codes, representing 8% of all births in NYC.19 The percent of residents who are 0-17 years old is as high as 29% in Brownsville, and all neighborhoods in the service area are younger and have higher birth rates than NYC overall.20 With the exception of mothers in Williamsburg, mothers in Wyckoff’s primary service area are more likely to receive late or no prenatal than are mothers in Brooklyn (6.0%) or New York State (5.6%). In East New York, 11.4% of mothers receive late or no prenatal care. The area is also disproportionately affected by poor birth outcomes. East New York’s infant mortality rate is the second highest in Brooklyn at 7.8 per 1,000 live births, and its pre-term birth rate is 11.6%. Teenage pregnancy rates are extremely high in the service area, with the rate in Bushwick at 40.8 per 1,000 births-- a rate 1.7 times higher than that of NYC overall. Many households are headed by single mothers, who are at higher risk for problems that compromise their health, expose them to various forms of violence and produce adverse birth outcomes for their babies. The table below summarizes maternal, infant and child health indicators for the Wyckoff primary service area: 18 Ibid. 19 New York State Department of Health: 2012-2014 New York State Vital Statistics Data as of June, 2015. 20 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 15 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Table 7: Maternal, infant and child health indicators for the Wyckoff primary service area Births Late/No Infant Pre-Term % 0-17 Teen Neighborhood 2012-14 Prenatal Mortality Births years old Births Absenteeism Bushwick 2,289 7.5% 5.0 9.0% 25% 40.8* 22% Ridgewood, Glendale, 6,629 7.6% 3.4 7.4% 22% 20.6 15% Maspeth, Middle Village Bedford Stuyvesant 6,022 8.0% 5.0 10.7% 25% 34.2 31% East New York 8,775 11.4%* 7.8* 11.6%* 28% 34.1 30% Williamsburg/Greenpoint 4,478 2.8% 2.4 6.0% 23% 20.1 19% NYC Overall 351,889 7.4% 4.7 9.0% 21% 23.6 20% * Indicates highest rate in the service area Breastfeeding. The benefits of breastfeeding for both mother and baby are numerous and well documented. Breastfed babies are less likely to have respiratory problems, ear infections and diarrhea.21 Mothers who breastfeed are less likely to develop breast or ovarian cancer and cardiovascular disease.22 The American Academy of Pediatrics recommends that babies be exclusively breastfed for the first six months of life, with the continuation of breastfeeding until one year of age or longer as mutually desired by mother and baby. While the benefits of breastfeeding are well known, many mothers face barriers to continued breastfeeding including hospital policies and practices,23 formula marketing and social norms,24 and work related factors.25 In New York City, breastfeeding rates differ by race/ ethnicity, poverty, neighborhood poverty, education and age. Women residing in high poverty neighborhoods, those who give birth as a teenager, and those with low educational attainment are much less likely to breastfeed beyond initiation, and these populations are highly represented among the women who give birth at Wyckoff. Breast Cancer. In Brooklyn, the mortality rate for breast cancer among women is significantly higher than that of New York City (NYC) and the State. Within NYC, Brooklyn has the lowest proportion of cases diagnosed at early stage, and one of the highest breast cancer mortality rates. 26 Data from Wyckoff’s tumor registry from 2012-2014 shows that more than 10% of our cases of breast cancer were proven to be Stage IV metastatic at presentation, compared to 9.2% of blacks and 5% of whites nationally. Locally, there are few support services, and patient navigation services are limited and differ in quality. Low rates of screening may be due to the many competing priorities in the lives of local women that often act as barriers to care. The cultural value that a mother or grandmother should place the needs of her family before her own is often encountered and expressed by our patients, as well as avoidance of healthcare due to fear of financial burden, and lack of insurance due to immigration status. Mental Health and Substance Use Most of Wyckoff’s catchment area is designated as medically underserved for both Primary Care and Behavioral Health, with significant access disparities for Primary Care and Psychiatry. According to the Center for Health Workforce Studies, in 2013 there were only 282 physicians per 100,000 persons in Brooklyn, a rate 34% lower than NYC’s overall rate of 428 per 100,000. The disparity for Psychiatry was 21 Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Baby Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare Research and Quality; April 2007. 22 World Health Organization. Fact File: 10 Facts on Breastfeeding. who.int/features/factfiles/breastfeeding/en. 23 Centers for Disease Control and Prevention. Breastfeeding-related maternity practices at hospitals and birth centers—United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:621–625. 24 Thulier D. Breastfeeding in America: a history of influencing factors. J Hum Lact 2009;25:85–94. 25 Satcher DS. DHHS blueprint for action on breastfeeding. Public Health Rep 2001;116:72-3. 26 2015-2019 Komen Greater NYC Community Profile Report. 16 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 even greater, with only 21 Psychiatrists per 100,000 persons in Brooklyn, a rate 57% lower than the NYC rate of 49 per 100,000. At the same time, Brooklyn, and particularly Northern and Central Brooklyn, have some of the highest rates of Psychiatric, Alcohol, and Drug related hospitalizations in NYC. 27 Lack of access to behavioral health is likely a significant causal factor for the high hospitalization rates seen in the region, and so providing accessible treatment options in primary care may help reduce these rates, as well as overall morbidity and mortality caused by behavioral health conditions. As healthcare delivery transformation unfolds, how service sectors share responsibility for a community’s behavioral health care is changing, with more care provided by medical providers in primary care settings. Primary care training enhancement is needed to ensure that people who would benefit have access to the necessary treatment modalities.28 Providers need to be knowledgeable about, and in some cases treat the most common mental health and substance use conditions in primary care.29,30 The need for new substance use treatment approaches is critical in Wyckoff’s service area. Within Brooklyn, Wyckoff serves the neighborhoods of Bushwick, East New York, and Bedford-Stuyvesant. These neighborhoods have the three highest rates of drug-related hospitalizations in Brooklyn – Bushwick’s rate is 1,309/100,000; East New York’s rate is 1,435/100,000; and Bedford-Stuyvesant’s rate is 1,830/100,000. These rates are nearly double that of New York City’s overall rate of 907/100,000.31 These rates indicate a significant unmet need for treatment. The following table summarizes behavioral hospitalizations in the Wyckoff service area: Table 8: Behavioral hospitalizations in the Wyckoff service area Neighborhood Psych Hosp Alcohol Hosp Drug Hosp Bushwick 744 1,515 1,309 Ridgewood, Glendale, Maspeth, Middle Village 302 603 319 Bedford Stuyvesant 1,060* 1,713* 1,830* East New York 1,030 1,534 1,435 Williamsburg/Greenpoint 466 976 678 NYC Overall 684 1,019 907 * Indicates highest rate in the service area Human Immunodeficiency Virus (HIV), Sexually Transmitted Infections (STI), Vaccine-Preventable Diseases (VPD), and Healthcare-Associated Infections (HAI) Human Immunodeficiency Virus (HIV). New York City continues to have one of the largest HIV epidemics in the United States, with 119,550 persons living with an HIV diagnosis and an additional 16,000 estimated to be infected but unaware of their status. In 2014, there were 2,718 new diagnoses in NYC, including 747 in Brooklyn and 464 in Queens. Within NYC, disparities by sex, race/ethnicity, risk factor, geography, and poverty level have persisted, resulting in a disproportionate burden among men who have sex with men (MSM), blacks and Hispanics, and persons living in high poverty neighborhoods. 27 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 28 Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Changing profiles of service sectors used for mental health care in the United States. American Journal of Psychiatry. July 2006; 163(7): 1187-1198. 29 Interorganizational Work Group on Competencies for Primary Care Psychology Practice. Competencies for Psychology Practice in Primary Care. March 2013. 30 Blount FA, Miller BF. Addressing the workforce crisis in integrated primary care. J Clin Psychol Med Settings. 2009;16(1):113-9. 31 New York City Department of Health and Mental Hygiene: Community Health Profiles, 2015. 17 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 The HIV epidemic continues to disproportionately impact minority populations such as the Hispanic and Black populations served by Wyckoff. In New York State, the rates of new HIV diagnoses among Hispanics and Blacks are 5.7 and 7.4 times higher, respectively, than the rate for Whites.32 In Brooklyn, Hispanic and Black persons accounted for 22.4% and 60.9%, respectively, of new HIV diagnoses in 2012.33 In the Wyckoff service area, the incidence of HIV is 34.8/100,000 compared to 27.9/100,000 in Brooklyn overall. In Bedford-Stuyvesant, the rate is 64.1/100,000, more than double the rate of Brooklyn or NYC overall.34 In addition to racial and ethnic disparities in the burden of HIV infection, Wyckoff’s service area also reflects the national trend that men who have sex with men (MSM) remain the population at greatest risk of HIV infection, and are the only group with increasing HIV incidence. Almost half of new diagnoses in Brooklyn and the Wyckoff service area are attributed to sexual transmission by MSM.35 These disparities result in a disproportionate burden of HIV infection in the Wyckoff service area. In New York City, HIV-positive Blacks and Hispanics are least likely to be virally suppressed,36 and in Brooklyn, 42% of persons aged 18-24 have never been tested for HIV.37 Based on this evidence, the marginalized populations served by Wyckoff are also likely to have lower awareness of HIV status, lower rates of linkage to and retention in care, and inadequate access to anti-retroviral treatment. 38 Sexually Transmitted Infection (STI). New York City STI data is reported by United Hospital Fund (UHF) neighborhoods, as opposed to Community Districts. The Wyckoff Service Area includes large portions of the Bedford Stuyvesant - Crown Heights, East New York, and Williamsburg-Bushwick UHFs in Brooklyn, and the West Queens and Ridgewood-Forest Hills UHFs in Queens. With the exception of Ridgewood- Forest Hills, the other neighborhoods in Wyckoff’s service area have some of the highest rates of STIs in NYC. Bedford-Stuyvesant/Crown Heights has the highest STI rates in Brooklyn, with rates 2-3 times higher than NYC overall rates: Table 9: 2015 STD rates in United Hospital Fund neighborhoods that overlap with the Wyckoff service area39 Neighborhood Chlamydia Rate Chlamydia Rate Gonorrhea Rate Gonorrhea Rate (Female) (Male) (Female) (Male) Williamsburg-Bushwick 1,434 765 119 403 Bedford-Stuyvesant/Crown Heights 2,577* 1,396* 197* 488* East New York 1,650 786 189 332 West Queens 1,737 556 54 155 Ridgewood-Forest Hills 406 213 19 65 NYC Overall 859 538 90 249 * Indicates highest rate in the service area Vaccine Preventable Diseases (VPDs). New York State and New York City have made progress towards meeting Healthy People 2020 goals for VPDs, but challenges remain in specific areas. New York City met or exceeded childhood immunization goals for Polio, MMR (Measles, Mumps, Rubella), Hepatitis B, 32 NYS HIV/AIDS Surveillance 2012 Annual Report (July 2014), p. 6 (http://www.health.ny.gov/diseases/aids/general/statistics/annual/2012/2012_annual_surveillance_report.pdf) 33 Table 20B http://www.health.ny.gov/diseases/aids/general/statistics/annual/2012/2012_annual_surveillance_report.pdf 34 NYC-DOHMH Community Profiles, 2015. 35 NYS HIV/AIDS Surveillance 2012 Annual Report (July 2014), p. 6 36 Wiewel and Mcallister-Hollod, “HIV care cascades for New York City overall and Ryan White clients: A first look,” 2013. (http://www.nyhiv.org/pdfs/NAC%20Presentation%206-13-13.pdf) 37 2012 NYCDOHMH Community Health Survey (https://a816-healthpsi.nyc.gov/epiquery/) 38 International AIDS Conference 2012, “Continuum of HIV care: differences in care and treatment by sex and race/ethnicity in the United States.” Irene Hall, CDC (http://pag.aids2012.org/Abstracts.aspx?AID=21098) 39 NYC-DOHMH Bureau of Sexually Transmitted Disease Control, 4th Quarter 2015 Quarterly Report, Vol. 13, No. 4. 18 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Varicella and influenza. However, NYC fell short of the Healthy People 2020 goals for the following VPDs: Haemophilus influenzae type b (Hib) vaccination for children 19-35 months old was 80.1%, compared to the 90% HP2020 goal Pneumococcal Conjugate Vaccine (PCV) of children 19-35 months old was 76.6%, compared to the 90% HP2020 goal Hepatitis A performance was only 47.8%, compared to the 85% HP 2020 goal Rotavirus Vaccination rate was 71.1%, compared to the 80% HP 2020 goal Regarding adolescent vaccination rates, New York City is ahead of the HP 2020 goal of 80%, with an 83% completion rate. Significant effort is needed, however, in uptake of the human papillomavirus (HPV) vaccine. Currently, only 43% of adolescent females have completed the HPV vaccine, while the HP2020 goal is 80%. While some neighborhoods in the hospital’s service area exceed this rate, some neighborhoods are even further behind, including Williamsburg (20%), Ridgewood (30%) and Bedford Stuyvesant (33%). Among adults, significant gains are needed to meet HP2020 goals for influenza vaccination, with only 54.8% of high risk adults vaccinated in the 2015-16 flu season.40 Healthcare Associated Infections (HAIs). Working toward the elimination of HAIs is a national priority. New York is one of ten state health departments in the Centers for Disease Control’s Emerging Infections Programs (EIP) network. Between 2013 and 2014, significant decreases were observed in New York State in Central Line-Associated Bloodstream Infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTIs), Surgical Site Infections (SSIs) during Abdominal Hysterectomy, and C. difficile Infections (CDI). When compared to National performance, however, New York State rates of CAUTI, SSI, and Methicillin-resistant Staphylococcus aureus (MRSA) were significantly higher. Antibiotic stewardship is becoming more important in light of increasing incidence of resistant strains of bacteria. New York was among 51 states and territories that received funding through the American Recovery and Reinvestment Act (ARRA) to strengthen state capacity for HAI surveillance and prevention. This funding is being used to implement and evaluate a Clostridium difficile (CD) Laboratory Identified Event reporting. The New York State Department of Health has funded and is continuing to support the CD prevention project in the greater New York City (NYC) metropolitan area. 40 https://www.cdc.gov/vaccines/vaxview/index.html 19 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Community Input and Prioritization Process Methodology. Wyckoff developed a short survey to obtain service provider, community, and other stakeholder input on the local importance of the New York State Prevention Agenda focus areas. Surveys were completed both online via Survey Monkey, and on paper in English and in Spanish. Paper surveys were collected at Wyckoff’s Community Health fair, other local community events, and at Community Based Organization (CBO) partner sites, including the Ridgewood YMCA and Make The Road New York. Participants were asked to think about the local community’s health and then rank the following focus areas, from most important (1) to least important (5): Preventing chronic diseases (obesity, tobacco use, nutrition) Promoting a healthy and safe environment (air, water, land use, injuries, violence) Promoting healthy women, infants and children (maternal and child health, reproductive health) Promoting mental health and preventing substance abuse Preventing HIV, Sexually Transmitted Diseases (STDs), Vaccine-preventable Diseases (VPDs), and Healthcare Associated Infections (HAIs) The Survey was administered with 230 participants, including 42 stakeholders (Wyckoff employees and community-based partners) and 188 local community residents. Sixty-Nine percent (69%) of local community residents surveyed lived in Wyckoff’s Primary Service Area, which is home to 75% of Wyckoff’s patients. Demographics of participants were as follows: Table 10: Demographic characteristics of community health survey participants Demographic Stakeholders Residents Total Gender: Female 31 (74%) 146 (78%) 177 (77%) Male 11 (26%) 41 (22%) 52 (23%) Transgender 0 (0%) 1 (<1%) 1 (<1%) Age: 10-19 0 (0%) 8 (4%) 8 (3%) 20-29 2 (5%) 43 (23%) 45 (20%) 30-39 18 (43%) 52 (28%) 70 (30%) 40-49 4 (10%) 31 (16%) 35 (15%) 50-59 11 (26%) 31 (16%) 42 (18%) 60-69 6 (14%) 20 (11%) 26 (11%) 70-79 1 (2%) 3 (2%) 4 (2%) Race/Ethnicity: Hispanic 13 (31%) 93 (49%) 106 (46%) Black/African American 7 (17%) 38 (20%) 45 (20%) White 14 (33%) 29 (15%) 43 (19%) Asian/Pacific Islander 5 (12%) 19 (10%) 24 (10%) Other 3 (7%) 9 (5%) 12 (5%) As indicated in the table below, stakeholders and local community residents agreed about the top priorities for Wyckoff’s service area, although the ranking order varied slightly. Despite these differences, the top two priorities were the same: Promoting Healthy Women, Infants, and Children and Preventing Chronic Diseases. In reviewing the community health profiles of Wyckoff’s service area and its demographic trends, Wyckoff’s community service plan targets chronic disease health disparities within the Hispanic population, including disparities in diabetes, obesity and breast cancer. The plan also targets maternal and child health disparities identified locally among both Blacks and Hispanics, including perinatal outcomes and breastfeeding. 20 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Table 11: Average priority score and corresponding rank by community health survey respondents Priority Area Stakeholders Residents Overall Promoting Healthy Women, Infants and Children 2.81 (2) 2.73 (1) 2.74 (1) Preventing Chronic Diseases 2.62 (1) 2.86 (2) 2.82 (2) Preventing HIV, STDs, VPDs, and HAIs 2.83 (3) 3.06 (4) 3.02 (3) Promoting a healthy and safe environment 3.62 (5) 3.04 (3) 3.15 (4) Promoting mental health and preventing substance abuse 3.12 (4) 3.30 (5) 3.27 (5) In addition to Wyckoff’s community survey, the New York City Department of Health and Mental Hygiene (NYC-DOHMH) conducted community consultations for Take Care New York 2020 in three regions served by Wyckoff: Bushwick, Bedford Stuyvesant, and Brownsville/East New York. The following table summarizes their findings and connects them to New York State’s Prevention Agenda Focus Areas, where possible. Areas where Take Care New York 2020 and community health survey priorities overlap will be specifically targeted by Wyckoff’s three year plan. The NYC-DOHMH did not conduct community consultations in any of the Queens regions served by Wyckoff. Table 12: Take Care New York needs prioritized through community consultation and relation to community health survey priorities Community Take Care New York 2020 New York State Prevention Agenda Focus Area Identified Priority Bushwick Child Care -Promoting healthy women, infants and children* High School Graduation Unmet Medical Need -Preventing chronic diseases* -Preventing HIV, Sexually Transmitted Infections, vaccine-preventable diseases, and healthcare-associated infections Unmet Mental Health Need -Promoting mental health and preventing substance abuse Violence -Promoting a healthy and safe environment Bedford Stuyvesant Controlled High Blood Pressure -Preventing chronic diseases* High School Graduation Unmet Medical Need -Preventing chronic diseases* -Preventing HIV, Sexually Transmitted Infections, vaccine-preventable diseases, and healthcare-associated infections Unmet Mental Health Need -Promoting mental health and preventing substance abuse Violence -Promoting a healthy and safe environment Brownsville/East New York Obesity -Preventing chronic diseases* Physical Activity -Preventing chronic diseases* -Promoting a healthy and safe environment Smoking -Preventing chronic diseases* -Promoting a healthy and safe environment Unmet Medical Need -Preventing chronic diseases* -Preventing HIV, Sexually Transmitted Infections, vaccine-preventable diseases, and healthcare-associated infections Unmet Mental Health Need -Promoting mental health and preventing substance abuse 21 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Partnerships In order to address the preventive health needs of our local community, Wyckoff engages in both multiple partner collaborations as well as individual community partnerships. Through these networks and partnerships, Wyckoff is able to better address non-medical determinants of health. Multiple Partner Collaborations and Networks. Wyckoff participates in a number of multiple partner collaborations and networks aimed at improving health in the local community: Delivery System Reform Incentive Payment Program. Wyckoff is an active member of the Community Care of Brooklyn (CCB) Performing Provider System (PPS) of the Delivery System Reform Incentive Payment Program (DSRIP). DSRIP brings together local hospitals, health centers, and community-based organizations into a system that aims to achieve better outcomes through coordinated care. CCB manages care collaboratively, sharing information via a DSRIP dashboard. Through DSRIP, Wyckoff has developed several programs related to prevention agenda focus areas: 30-Day Readmissions Project - A team of Transitional Care Nurses and Care Managers develops care plans with patients prior to discharge and ensures supports and follow-up care are available in the home as needed. Through this project, Wyckoff is collaborating with the Jewish Association Serving the Aging (JASA), whose home-visiting team meets with select patients on the inpatient unit and follows up with them in the home within 48 hours. Emergency Department Triage Project - Two ED Navigators work to reduce unnecessary ED utilization by meeting with patients and scheduling their follow-up care with Primary Care Providers and Behavioral Health Providers. This team also works closely with onsite Health Home Navigators to coordinate care, in an attempt to reduce ED utilization for primary care or behavioral health sensitive conditions. PCMH+/IMPACT Project - Health Coaches work with patients on chronic disease self- management goals, coordinate care with primary care providers, and provide and follow-up on specific referrals to ensure high quality, patient-centered care. Primary Care Providers screen for and manage common mental disorders including depression and anxiety with the support of Depression Care Managers and a consulting Psychiatrist. Breathe Easy Asthma Team (BEAT) - Community Health Workers conduct home visits to identify triggers, provide asthma education to individuals and families, and ensure effective engagement in Asthma action plans with Primary Care Providers. This program is a resource to the entire PPS, meaning Wyckoff works to reduce unnecessary ED utilization and hospitalizations for all community members, not just those who receive medical care at Wyckoff. The program also includes a partnership with the local community-based organization, Make the Road New York, who trains Spanish-speaking Community Health Workers. Brooklyn Health Home. A Health Home is a care management service model whereby all of an individual's caregivers communicate with one another-- this enables all of a patient's needs to be addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared among providers so that services are not duplicated or neglected. Health Home services are provided through a network of organizations – providers, health plans and community-based organizations. Wyckoff has established a highly effective partnership with Maimonides Medical Center and the National Association on Drug Abuse Problems (NADAP) to establish a health home in Brooklyn with a special competency in caring for patients with two or more chronic conditions. As part of this 22 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 collaboration, Wyckoff houses NADAP Care Managers in the Emergency Department to identify patients at high-risk for inappropriate ED utilization or avoidable admission, and connects them to needed primary care and behavioral health services. Maternal Depression Quality Collaborative. In 2015, Wyckoff joined several other hospitals, the New York City Department of Health and Mental Hygiene and the Greater New York Hospital Association to form the Maternal Depression Quality Collaborative. Participating hospitals share best practices and implement quality improvement processes to screen all expectant and postpartum mothers for depression, and connect them with services as necessary. Despite an estimated 13% of mothers who suffer from postpartum depression, with half of these cases originating during pregnancy, screening for depression among pregnant and postpartum women currently is still not routine. As a part of this collaborative, Wyckoff introduced universal depression screening into the Women’s Health Center work flow and established a depression care manager at the site to connect women to depression treatment and support services. New York City Breastfeeding Hospital Collaborative. The aim of the New York City Breastfeeding Hospital Collaborative is to increase the number of NYC’s maternity facilities that achieve Baby-Friendly Designation by September 2020. Wyckoff is a member of Cohort 3 and has completed the first two phases of the Baby Friendly Hospital Designation Process. The teaching and learning collaborative consists of birthing centers that work together to institute Baby Friendly-USA’s Ten Steps to Successful Breastfeeding. Each hospital assigns a multidisciplinary leadership team to participate in quarterly meetings and to report their quality improvement efforts and breastfeeding data. The team includes nursing and physician leadership from Obstetrics and Gynecology, Wyckoff’s Lactation Consultant, and representatives of the WIC Program, to ensure support for breastfeeding across the perinatal continuum. HIV and Hepatitis C Regional Planning and Prevention Groups. Wyckoff is an active participant in regional collaborative groups working to end the HIV and Hepatitis C epidemics. Wyckoff leadership has been appointed by the Mayor of NYC to serve on the Ryan White Planning Council to develop and implement effective HIV primary care support services. Wyckoff also is active on NYC’s HIV Planning Group, a network of more than 100 HIV prevention service providers across the city. Wyckoff participates in the “Brooklyn Knows” campaign, which aims to make every Brooklyn resident aware of his or her HIV status through awareness and testing activities. Physicians and administrative leadership also participate in NYC’s Hepatitis C Research Consortium and Hepatitis C Clinical Information Exchange Network to share and disseminate best practices in Hepatitis C screening, linkage to care, and treatment. Individual Partners and Collaborative Service Agreements. Wyckoff has established an extensive and diverse network of individual community partners through linkage and service agreements, memoranda of understanding, and subcontracts to meet the holistic needs of our patients and address the full range of determinants of health. The following table summarizes these agreements, the collaborative services provided, and related prevention agenda focus areas: 23 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Table 13: Wyckoff collaborative partners, services provided and related prevention focus areas Collaborative Partner Services Provided Prevention Focus Areas After Hours Project Substance Use Prevention and Treatment Promoting Mental Health and Preventing Substance Use Bushwick Brightstart Home Based Child Development Services Promoting Healthy Women, Infants and Children Brownsville Multiservice Center Medical Care for the Uninsured Preventing Chronic Diseases Bushwick Center Adult Day Care Adult day care services, senior services, comfort care, Preventing Chronic Diseases palliative care services Brooklyn District Attorney’s Office Violence Prevention and Intervention Promoting a Healthy and Safe Environment Brooklyn Plaza Medical Center Medical Care for the Uninsured Preventing Chronic Diseases CAMBA Housing, Legal, and HIV support services Promoting a Healthy and Safe Environment; Preventing HIV, STDs, VPDs, and HAIs Centering Healthcare Institute CenteringPregnancy Training Promoting Healthy Women, Infants and Children Centerlight PACE Program Preventive Services for Seniors Preventing Chronic Diseases Cicatelli Associates HIV Prevention Education Preventing HIV, STDs, VPDs, and HAIs Coalition for Hispanic Family Services After school and youth services in Spanish Promoting Healthy Women, Infants and Children Community Cares of Brooklyn (CCB) Delivery System Reform Incentive Payment Program All (DSRIP) Community Healthcare Network Mobile mammography, medical care for the uninsured Promoting Healthy Women, Infants and Children; Preventing Chronic Diseases Cornerstone Treatment Facilities Network Comprehensive Substance Abuse Treatment Services Promoting Mental Health and Preventing Substance Use Daya Yoga Exercise Classes Preventing Chronic Diseases El Puente Youth Center After School and Youth Development Services Promoting Healthy Women, Infants and Children Family Services Network of New York Syringe-Exchange and Harm Reduction Program Promoting Mental Health and Preventing Substance Use; Preventing HIV, STDs, VPDs, and HAIs Fund for Public Health in New York Healthy Start Brooklyn, CenteringPregnancy Promoting Healthy Women, Infants and Children Gay Men of African Descent Outreach to young men who have sex with men Preventing HIV, STDs, VPDs, and HAIs (YMSM) God’s Love We Deliver Meals Delivery Promoting a Healthy and Safe Environment Hope Gardens Housing Project with Community Center Promoting a Healthy and Safe Environment Housing Works Housing and support services for persons living with Promoting a Healthy and Safe Environment; HIV/AIDS Preventing HIV, STDs, VPDs, and HAIs Jewish Association Serving the Aging Post-discharge home visiting program Preventing Chronic Diseases La Nueva Esperanza Food and nutrition services for persons living with HIV Preventing HIV, STDs, VPDs, and HAIs Latinos Diferentes Outreach to Hispanic persons who identify as Preventing HIV, STDs, VPDs, and HAIs transgender Make the Road New York Insurance navigation and support services for All undocumented persons and new immigrants NADAP Health Home Enrollment Preventing Chronic Diseases; Promoting Mental Health and Preventing Substance Use New Directions Outpatient Substance Use Treatment and Harm Promoting Mental Health and Preventing Substance Reduction services Use New Life Child Development Center Day Care/Child Care Promoting Healthy Women, Infants and Children New York Council on Adoptable Children Parenting, Legal Services, Daycare Promoting Healthy Women, Infants and Children New York Psychotherapy and Counseling Mental Health Services Promoting Mental Health and Preventing Substance Center Use NYC Alliance Against Sexual Assault Violence Prevention and Intervention Training Promoting a Healthy and Safe Environment NYC LGBT Community Center LGBT services including behavioral health, HIV Promoting Mental Health and Preventing Substance prevention, and youth services Use; Preventing HIV, STDs, VPDs, and HAIs NYC Department of Parks Exercise Classes Preventing Chronic Diseases NYPD 83rd Police Precinct Collaborate in response to violence and sexual Promoting a Healthy and Safe Environment assault Opportunities for a Better Tomorrow Educational and vocational services Promoting a Healthy and Safe Environment Outreach Project Outpatient substance abuse treatment, syringe Promoting Mental Health and Preventing Substance exchange and harm reduction Use; Preventing HIV, STDs, VPDs, and HAIs Partnership for the Homeless Housing and homeless services Promoting a Healthy and Safe Environment Regional Aid for Interim Needs (RAIN) Home-delivered meals, transportation, case Preventing Chronic Diseases; Promoting a Healthy management and elder abuse services for seniors and and Safe Environment persons with disabilities 24 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Ridgewood Bushwick Senior Citizens Council Housing and senior services Promoting a Healthy and Safe Environment; Preventing Chronic Diseases Ridgewood YMCA Exercise Classes; Cancer Support Group Preventing Chronic Diseases; Promoting Healthy Children and Youth Services Women, Infants and Children Translatina Network Health education and outreach to Hispanic Preventing Chronic Diseases Transgender persons Unidine Healthy Meals Program; Nutrition Education; Preventing Chronic Diseases Farmer’s Market University of Washington AIMS Center Technical Assistance for Behavioral Health Integration Promoting Mental Health and Preventing Substance Use Violence Intervention Program (VIP Mujeres) Bilingual psychotherapy for survivors of violence Promoting a Healthy and Safe Environment 25 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 ADDRESSING PREVENTION chronic diseases. Under DSRIP, Wyckoff is AGENDA FOCUS AREAS working towards achieving PCMH Level III status across multiple primary care sites. Health Wyckoff Heights Medical Center is a community Coaches have been hired and trained to identify service oriented hospital with a diverse patients with specific chronic disease risk portfolio of special projects designed to address profiles (Cardiovascular and Diabetes risk) and New York State’s Prevention Agenda areas of work with those patients and their providers to focus. While two priorities were selected to develop self-management goals. Health include in the three-year community service coaches then work with patients to develop plan, this section will describe Wyckoff’s work these goals into a patient-centered care plan. to address all areas of focus. Wyckoff has also established Emergency Department navigators responsible for Preventing Chronic Diseases intervening with patients who present for primary care or behavioral health sensitive Primary Care Expansion and PCMH Work. conditions and ensuring they obtain follow-up Regular engagement in primary medical care is care. Since transitional periods create a crucial factor in preventing chronic diseases vulnerable periods for patients who have been and mediating their deleterious effects. As hospitalized, Wyckoff has established a described in the needs assessment, Wyckoff is Transitions of Care Unit that develops post- located in a severe primary care shortage area, discharge care plans and follows up with which is likely contributing to poor health patients. This unit obtains patient consent to outcomes. To better prevent chronic diseases, share medical information across multiple Wyckoff has greatly expanded its primary care providers for effective coordination of care, and service since 2012, and has achieved annual collaborates with the Jewish Association of volume increases of more than 15% year over Services for the Aging (JASA) whose social year. New local community-based primary care workers meet with patients prior to discharge sites have been established, including the and follow-up in the home post-release to Pediatric Care Center (2014), the Wyckoff ensure food security, prescriptions are filled, Medical Arts Building (2015), and Wyckoff caregivers are present, and patients attend Doctors (2016). Other sites have undergone follow-up outpatient care visits. enhancements to improve accessibility and patient flow (Women’s Health Center, 2015). Through the Delivery System Reform Incentive Unidine Services. In 2016, Wyckoff engaged a Payment program (DSRIP), Wyckoff has been new partner, Unidine, in the delivery of food awarded $53 Million to reorganize the hospital services to patients, staff and the community. plant to create more space for primary care, Unidine is committed to scratch cooking with care management, and community services. fresh, seasonal, and responsibly sourced Wyckoff also was awarded more than $5.5 ingredients. Through Unidine, Wyckoff offers Million to establish new community-based OH SO GOOD, kitchen-tested recipes supporting primary care sites. healthy food and lifestyle choices. OH SO GOOD menu items’ nutritional guidelines While primary care access is critical, systems, include high fiber, high vitamins and minerals processes, and coordination are also important content, only lean proteins, unsaturated fat in preventing chronic diseases and poor chronic sources only, low sodium, and health promoting disease outcomes. Therefore, Wyckoff is culinary techniques only. Unidine has been engaged in several collaborative initiatives leveraged to address community needs and involving community partners to better build Wyckoff’s presence in the community with coordinate care and improve management of programs including nutrition education, cooking 26 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 demonstrations, health fairs, farmers markets, beneficiaries, engage high risk patients in and community dinners. shared decision making, develop individual risk modification plans, and complete annual risk Wyckoff Employee and Community Wellness reassessment. Programs. In an effort to prevent obesity and reduce risk of cardiovascular disease and other chronic conditions through physical activity, Promoting a Healthy and Safe Wyckoff renovated space in 2015 to create an Environment exercise room, where a variety of wellness Violence Intervention and Treatment Program. offerings are provided for staff and the WHMC’s Violence Intervention and Treatment community. Wyckoff has partnered with local Program (VITP) is the only hospital-based rape businesses and the parks department to offer crisis program (RCP) certified by the New York free weekly Yoga and Zumba classes. State Department of Health (NYSDOH) in the borough of Brooklyn. Since 2004, VITP has been ¡Vida SI, Diabetes NO! Diabetes is a major an experienced provider of sexual assault, rape, problem in Wyckoff’s service area, and the childhood sexual abuse, stalking, dating disparities within the Hispanic community are violence, and domestic/intimate partner well documented. Therefore Wyckoff is an violence services, including 24/7 hotline, crisis active participant in ¡Vida Si, Diabetes No!, a and ongoing counseling, personal advocacy, major awareness raising campaign that includes criminal justice advocacy, accompaniments, hospitals, health centers, Hispanic-serving compensation assistance, information and organizations, the American Diabetes referrals, as well as prevention and education Association, and Hispanic media outlets. This services within the hospital and larger initiative is designed to mobilize the community. All services are free, confidential community, increase access to screening, and and available in English and Spanish, regardless engage persons with diabetes or at high-risk for of immigration or insurance status. In 2015, the diabetes to culturally-relevant treatment. VITP served more than 250 survivors of Wyckoff will serve as a local hub for Spanish domestic violence and/or sexual assault. The language screening, education, and access to VITP works with community partners including diabetes self-management groups. the Police Department, District Attorney’s office, New York Alliance Against Sexual Assault, Million Hearts Initiative. Million Hearts is a and VIP Mujeres, a local Hispanic survivors national initiative with an ambitious goal to services organization. prevent 1 million heart attacks and strokes by 2017. The Centers for Disease Control and In 2014, Wyckoff instituted a Sexual Assault Prevention and the Centers for Medicare & Nurse Examiner (SANE) Program to enhance the Medicaid Services co-lead the initiative on quality of health care for women who have behalf of the U.S. Department of Health and been sexually assaulted and improve the quality Human Services. Wyckoff is a participant in the of forensic evidence to enable prosecution. The Million Hearts CVD Model, which tests a new VITP is integrated with clinical services in the model of payment for Medicare fee-for-service Emergency Department (ED), and currently beneficiaries who meet the eligibility criteria. houses four SAFE-certified nurse examiners and The model promotes CVD prevention and aims one SAFE-certified OB/GYN Physician for the to improve CVD outcomes through risk purposes of assessing and evaluating survivors assessment and risk management. Through of sexual assault and intimate partner violence. Million Hearts, Wyckoff’s Primary Care Every sexual assault survivor is treated by a Providers will enhance Cardiovascular Disease physician, and our ED staff has experience Risk Stratification, identify high-risk treating the wide range of violence related 27 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 injuries. The ED also has established post- established strong relationships with local exposure prophylaxis (PEP) and emergency organizations working to provide access to contraception rapid access protocols. The VITP housing, housing subsidies, eviction prevention, has 24 trained Rape Crisis Volunteer Advocates advocacy, and other housing-related services, who provide calm, consistent, knowledgeable including Make the Road New York, Housing support to enhance the efforts of ED staff and Works, Ridgewood-Bushwick Senior Citizen’s ensure no survivor is ever left alone. Council, and CAMBA. In 2014, New York State signed into law the Project Search. In 1995 the American College of most aggressive policy in the nation to fight Healthcare Executives adopted a policy against sexual assault on college campuses. The statement that reads, "...healthcare executives new “Enough is Enough” legislation requires all must take the lead in their organizations to colleges to adopt a set of comprehensive increase employment opportunities for procedures and guidelines, including a uniform qualified persons with disabilities and to definition of affirmative consent, a statewide advocate on behalf of their employment to amnesty policy, and expanded access to law other organizations in their communities." To enforcement. In 2015, the Wyckoff’s VITP was address this issue, Wyckoff serves as a site for funded to provide technical assistance, Project SEARCH – a program that provides education, and access to VITP services for employability skills training and workplace colleges in Brooklyn and Queens, and has internships for individuals with significant established multiple memoranda of disabilities, particularly youth transitioning from understanding with local colleges to engage high school to adult life. Participants are them in violence prevention work. recruited from the local community and are employed across a range of departments where Participation in Community Board 4 (CB4). they learn skills that are amenable to ongoing Wyckoff is a regular participant in CB4 employment. After program completion, meetings, where the hospital provides input several participants have achieved employment into many community board planning processes within the hospital itself. related to the neighborhood environment, including land use and zoning, identifying community needs as part of the City’s budget Promoting Healthy Women, Infants process, and working with government agencies and Children to improve the local delivery of services. A Wyckoff Heights Medical Center has instituted significant focus area for CB4 in recent areas several community service projects to promote has been in addressing issues related to the healthy Women, Infants and Children: gentrification of the neighborhood, and how this has affected the health and well-being of Women’s Health Center. The Women’s Health local families. Center provides a medical home for women including Primary Care, Obstetrics/Gynecology, Partnerships with Housing Organizations. and family planning. Because the community is Factors related to housing have the potential to majority Hispanic, with a significant proportion help—or harm—our health in major ways. who use Spanish as their primary language, Housing stability, physical conditions, conditions Wyckoff has employed several bi-lingual in the neighborhoods surrounding homes, and Spanish medical providers at the Women’s housing affordability not only shape home and Health Center. The Women’s Health Center neighborhood conditions but also affects the offers CenteringPregnancy, an evidence-based overall ability of families to make healthy model of group prenatal care with three major choices. For these reasons, Wyckoff has components: health assessment, education and 28 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 support. The model has been shown to improve Care Center serves a population that is 65% health outcomes for mothers and babies, Hispanic, including more than 25% monolingual- including lowering rates of preterm birth, which Spanish. In 2015, the Pediatric Care Center is the leading cause of infant mortality. The provided 32,894 visits to 9,408 unique patients model also engages women more meaningfully age 0-17 years old including 4,440 unique in self-care, offers more time with the provider, patients age 0-5. Sixty-five percent of these and encourages friendship and support among patients were insured by Medicaid. The participants. The Women’s Health Center also average number of unique newborns seen collaborates with Wyckoff’s Positive Health monthly in 2015 was 82.3. In 2014, the Management program to provide individual and Pediatric Care Center integrated behavioral group risk reduction counseling, free HIV, health at the site, and now offers seven Hepatitis C, and Sexually Transmitted Infections sessions of Pediatric Behavioral Health per (STI) screening and STI treatment to uninsured week, delivered by a bi-lingual Pediatric Clinical women and their partners. Risk for depression Psychologist. The site also employs a Child Life in women increases during pregnancy and in Specialist who uses a combination of the first post-partum year. Therefore, the psychology, play therapy, and a wide array of Women’s Health Center participates in the New calming techniques to improve the pediatric York State maternal Depression Collaborative. experience. As a participant, the Women’s Health Center has committed to screening 100% of pregnant Women, Infants and Children (WIC) Program. and postpartum women for depression, and Wyckoff’s WIC program has provided a connecting them with treatment. longstanding and critical mechanism to reduce obesity, improve food security, promote Pediatric Care Center. Wyckoff has a growing positive birth outcomes, increase breastfeeding Department of Pediatrics, which includes both rates, and reduce health disparities and the risk inpatient and outpatient services and a newly for chronic disease among local women, infants established (2014) Pediatric Residency Program and children. WIC offers participant-centered with eight active residents. Wyckoff’s and culturally-responsive nutrition assessment community-based, outpatient Pediatric Care and education; breastfeeding promotion and Center has grown from 7,744 individual patients support, including Breastfeeding Peer age 0-17 in 2013 to 9,408 in 2015 – a growth Counseling and breast pumps; referrals to rate in the patient population of more than 10% health and social services; and a variety of per year. This growth is a result of both a local nutritious foods. In 2015, the WIC program community with an extremely high birth rate, served approximately 7,000 unique participants and Wyckoff’s strategic objective to meet the across two neighborhood sites. needs of the local community by expanding accessible Pediatric outpatient services. In WIC is a key component to Wyckoff’s strategy 2013, Wyckoff opened a new community-based to improve breastfeeding within our Pediatric site at 1411 Myrtle Avenue, the community. A key component of the program Wyckoff Pediatric Care Center, which offers is the Enhanced Breastfeeding Peer Counselor comprehensive Pediatric Primary Care and co- Program, which connects with women located subspecialties including hematology, prenatally, engages them on the Obstetrics unit, neurology, endocrinology, pulmonology, and supports breastfeeding across the first year podiatry, nutrition and gastroenterology. The of life. Breastfeeding Peer Counselors utilize a Pediatric Care Center was established at its prenatal participant list and a newborn infant location because it is adjacent to several child list to ensure all eligible women are assigned a care centers, a school, and other key services counselor, and the Breastfeeding Coordinator for children and families. The Wyckoff Pediatric evaluates breastfeeding initiation, duration and 29 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 status reports routinely and reviews literacy strategies into prenatal care, and the breastfeeding activities, education and peer CenteringPregnancy model of group prenatal counseling for effectiveness monthly. The WIC care. MICHC also hosts community baby Program’s community-based centers maintain a showers every month. A fundamental principle breastfeeding friendly environment, of MICHC is to bring the patient and doctor encouraging women to breastfeed openly or in together to provide superior health care any way that is comfortable for them. WIC services through patient empowerment and promotes and supports breastfeeding through physician engagement. MICHC activities the provision of breastfeeding education and encourage women to seek out family planning counseling; the purchase and issuance of breast services, to seek more preventive care and thus pumps; and the coordination of care with reduce their reliance on costly emergency care, lactation consultants and health care providers seek prenatal care earlier and maintain healthy to ensure that medical challenges to lifestyles. breastfeeding are addressed. Healthy Steps Program. The goal of Wyckoff’s The WIC Program is also a part of the hospital’s Implementation of Healthy Steps program is to plan to address obesity, through its Obesity improve children’s social-emotional well-being Intervention Program for children ages 2-5 and growth; improve child development years old and its health lifestyle program, outcomes; reduce health disparities; and “FitWIC.” FitWIC includes a farmer’s market improve quality and the patient experience. The incentive program, healthy recipes, food Healthy Steps program works towards these demonstration and physical activities, such as goals by establishing a multidisciplinary Healthy Zumba in the Park. The program has an on-site Steps Implementation team and embedding a community garden, where participants can Healthy Steps Specialist within the Wyckoff’s learn about healthy and nutritious vegetables. Pediatric Care Center. Together, the implementation team and Healthy Steps Maternal and Infant Community Health Specialist have established the following: Collaborative (MICHC Program). With MICHC enhanced screening practices, enhanced well- funding, Wyckoff is building a health child visits, home visits, child development and improvement zone for women of northern and family health check-ups, a child developmental eastern Brooklyn. The MICHC Program is telephone information line, expanded Reach designed to reach and engage women of Out and Read program to promote literacy, childbearing age and provide education and parent support groups, improved management support services that address specific health of community referrals, and dissemination of inequities within the local populations we serve. prevention and health promotion informational These include education and support services materials in English and Spanish. The Healthy for teen-age mothers and Hispanic, African Steps program collaborates with select local American, and Foreign-Born women and their child and family services organizations, families. The program uses community including Bushwick Brightstart Healthy Families assessment, consensus building, and the Program; Brooklyn Healthy Start; the local development of education, outreach and YMCA; the Council on Adoptable Children; El marketing strategies to reach women Puente Youth Center; Opportunities for a Better throughout all stages of life course and their Tomorrow; Hope Gardens; Coalition for children. The program has also implemented Hispanic Family Services; local day-care centers; approaches that have a strong evidence base in and Make The Road New York, that provides support of their ability to reduce disparities in significant programming and services for outcomes, including Baby Basics, a program to undocumented persons and new immigrant integrate evidence-based materials and health families. 30 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 every day these providers are presented with Her Health First Program. Wyckoff has patients who have mental health conditions and implemented “Her Health First/Mi Salud needs. Therefore, in 2014 Wyckoff hired its first Primaria” (HHF), a creative, culturally tailored Director of Behavioral Health, charged with breast health screening coordination and integrating behavioral health care and patient navigation program designed to reduce modalities in Wyckoff’s primary care settings. disparities in breast cancer mortality for women of color by improving access and coordination Behavioral Health Screening Initiatives. Critical of screenings, diagnosis, and treatment. HHF to behavioral health integration is the targets primarily Hispanic and Black women, identification of behavioral health needs age 40 and older, of low socioeconomic status through screening. In 2015, Wyckoff launched in the underserved Brooklyn neighborhoods of initiatives to improve depression screening, Bushwick, East New York, and Bedford including participation in the Maternal Stuyvesant, and the Queens neighborhood of Depression Quality Collaborative, training of Ridgewood/Glendale. HHF employs outreach medical providers and nursing staff on and in-reach by community health workers to depression screening tools (PHQ2/9), and engage women in screenings; and patient institution of universal depression screening navigation and peers to improve linkage to across Wyckoff’s primary care settings. In 2016, diagnostic and cancer care. The program Wyckoff incorporated additional behavioral includes key community partnerships, including health screenings into the electronic medical Community Healthcare Network to provide record, including the Generalized Anxiety Mobile Mammography for the uninsured; Disorder Assessment (GAD-7), the Drug Abuse CAMBA and Ridgewood-Bushwick Senior Screening Test (DAST-10) and the Alcohol Use Citizens Council to provide insurance Disorders Identification Test (AUDIT). enrollment, family support, housing and economic development services; Make the Collaborative Care/IMPACT. Wyckoff is Road New York to provide services for new instituting the Collaborative Care/IMPACT immigrants; and the Ridgewood YMCA model across all of its Article 28 primary care LIVESTRONG and Bushwick Center Adult Day settings. The Collaborative Care/IMPACT Model program to provide support groups, homecare, is an approach to integration in which primary and palliative care services for women who care providers, care managers, and psychiatric undergo treatment. consultants work together to provide care and monitor patients’ progress. These programs Promoting Mental Health and have been shown to be both clinically-effective Preventing Substance Abuse and cost-effective for a variety of mental health conditions in primary care settings, using A primary gap identified within the Wyckoff several different payment mechanisms. system of care is the lack of Mental Health and Collaborative Care/IMPACT is supported at Physical health integration. Empirical evidence Wyckoff through a Primary Care Training suggests that behavioral health integration will Enhancement grant from the Health Resources be central to health system transformation and and Services Administration, which trains improving access, population health, experience Primary Care Providers, Residents and of care, and per-capita costs. Behavioral Health Behavioral Health Providers across multiple at Wyckoff is in early stages of implementation, departments to implement the model. The so residents and primary care providers DSRIP program supports the start-up costs for currently receive little training in mental health, Depression Care Managers to work in the and limited exposure to working with primary care sites as well as telepsychiatry behavioral health providers. At the same time, consults. The service will be sustained through 31 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 new enhanced payments and value-based Preventing HIV, Sexually payment methodologies being rolled out Transmitted Infections, Vaccine- statewide. Preventable Diseases, and Healthcare-Associated Infections Buprenorphine Program. In 2016, Wyckoff began the process of instituting buprenorphine Positive Health Management (PHM). Wyckoff treatment by primary care providers using a and its Positive Health Management program Nurse Care Manager (NCM) model, based on has been at the forefront in addressing the the Buprenorphine Collaborative Care model HIV/AIDS epidemic and its related cofactors implemented at Boston Medical Center in since the early years of the HIV epidemic. PHM Massachusetts. In this model, and consistent is dedicated to providing excellent, accessible, with the principles of the patient-centered and quality prevention and medical care to medical home, a dedicated NCM works with persons who are at risk for or who are living physicians to deliver team-based care for with HIV, Hepatitis C (HCV), and sexually patients being treated for opioid use disorders. transmitted infections (STI). Our Together, the team screens and assesses multidisciplinary team includes physicians who patients, performs medication management are specialists in the treatment of HIV and and motivational counseling, and refers for infectious disease, nurses, social workers, case more intensive treatment as necessary. The managers, mental health counselors, and model also includes access to local mentors prevention specialists. Our caring and who are experienced in buprenorphine compassionate staff represent the diversity of prescribing to provide additional support and our community, and are multilingual, LGBT- case review as needed. friendly, and culturally competent. We provide an array of individual and group activities and Behavioral Health Partners. In addition to resources in the clinic, and maintain strong and behavioral health integration projects, Wyckoff effective relationships with community partners meets community needs through formal to support patients in achieving their holistic partnerships with behavioral health service goals. providers, including New York Psychotherapy and Counseling Center, Cornerstone Treatment Routine HIV and HCV Screening Initiatives. Facilities Network, New Directions Outpatient Wyckoff’s PHM has been an integral part of Substance Abuse Treatment Center, the After preventing HIV by ensuring the hospital’s Hours Project Syringe Exchange and Harm compliance with New York State’s HIV and HCV Reduction Program, the NYC Lesbian, Gay, testing laws. The department has worked Bisexual and Transgender Community Center closely with leadership and multiple divisions Center Wellness Program, the Outreach Project, and departments to institute policy changes, Housing Works, the Coalition for Hispanic integrate routine screening processes, optimize Family Services, and others. Wyckoff has active electronic systems and conduct quality service agreements with all of these mental improvement projects related to HIV and HCV health and substance use disorder treatment screening and linkage to care. As a result of programs. these efforts, Wyckoff has seen significant volume increases in HIV and HCV testing, conducting more than 12,000 HIV tests and more than 5,500 HCV tests in 2015 alone. Targeted HIV Prevention Projects. In addition to routine screening efforts, PHM works to 32 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 prevent HIV infections through multiple delivered services for newly diagnosed persons targeted HIV prevention projects. These efforts and persons with a detectable viral status; the target disproportionately affected and Care Coordination program, which provides vulnerable populations including Hispanic and health education, home visits, patient Black young men who have sex with men navigation, and directly observed therapy for (YMSM), Transgender persons, Hispanic persons at risk for poor medication adherence; women, and undocumented persons. PHM and “The Undetectables,” a social marketing utilizes novel approaches to engaging high risk campaign developed by one of Wyckoff’s persons including outreach through social community partners, Housing Works. The media applications. PHM partners with local Undetectables honors viral suppression as a community organizations to engage hard-to- heroic act and provides financial incentives to reach persons at high risk. These organizations patients who achieve and maintain suppression. include Gay Men of African Descent (to reach Through these innovative projects, Wyckoff’s Black YMSM), Latinos Diferentes (to engage HIV Primary Care population has achieved a Young Hispanic Men), Translatina Network (to consistent viral suppression rate of 89%. reach Hispanic Transgender Persons), and Wyckoff’s WIC Program (to engage Hispanic Hepatitis C Screening, Navigation and Women). All prevention services and Treatment. Wyckoff has worked to expand screenings for targeted populations, including capacity to better identify cases of untreated HIV, HCV, and STI screening, as well as STI HCV, improve linkage to clinical evaluation and treatment, are provided free of charge to the treatment, and cure patients using the latest uninsured. advanced pharmacological treatment options. As a result of participating in NYC’s Hepatitis C Biomedical HIV Prevention. PHM provides rapid Research Consortium and Hepatitis C Clinical access to biomedical prevention interventions Information Exchange Network, Wyckoff has including HIV Post-Exposure Prophylaxis (PEP) been able to increase data collection capacity to and Pre-Exposure Prophylaxis (PrEP). Wyckoff measure its performance on the HCV care has been funded to institute access to these continuum and track patients through interventions across all of its primary care sites. screening, diagnosis, treatment and cure. In 2015, PHM became a New York State Wyckoff has also established an HCV navigation designated PrEP Assistance Program site, program to support patients move along the meaning it can bill for medications and continuum of care, providing health education, treatment provided to the uninsured, free of navigation, outreach, and psychosocial support. charge. Through participation in the Governor’s Ending the Epidemic Initiative, Wyckoff was STI Screening and Treatment Program. PHM selected as a site to institute “Status-Neutral operates a comprehensive sexual health clinic Care Coordination,” a program that provides that includes prevention education, screening, care coordination, patient navigation, and and treatment to the community, including free supportive services to HIV negative persons at services for the uninsured. PHM follows up high risk for acquiring HIV, to help them with STI cases from other departments, maintain their HIV negative status. including pediatrics, women’s health center, and emergency department, to support Treatment as Prevention. PHM operates patients in completing treatments, testing several programs that aim to support patients partners, and providing health education and in achieving HIV viral suppression, which risk reduction counseling. prevents transmission of HIV to partners. These include the Retention and Adherence Program, which provides case management and peer 33 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Healthcare Associated Infections and Antibiotic Although antibiotic stewardship commonly has Stewardship. Wyckoff has instituted a been prioritized within inpatient hospital comprehensive quality improvement plan for settings, there is a critical need to better improving HAIs. In addition, the Infectious understand how much variability in prescribing Disease Division in collaboration with exists in ambulatory settings and whether Pulmonary -Critical Care Division updated and practice-level data can offer useful information implemented new Adult and Pediatric Sepsis to guide stewardship efforts. Research has Protocols in 2015. This allows Wyckoff to shown that a modest reduction of 10% in quickly identify patients with severe sepsis and outpatient antibiotic prescribing could yield a septic shock, to improve adherence to early substantial decrease in community-acquired goal directed therapy and fast administration of Clostridium difficile, and so implementing appropriate broad-spectrum antibiotics, and to outpatient interventions in order to reduce improve pressure support management and inappropriate antibiotic use is essential. Studies patient’s disposition. This quality improvement of outpatient antibiotic use have been initiative is aimed at improvement of sepsis conducted across the nation, and findings management and clinical outcomes. suggest a high degree of inappropriately prescribed antibiotics for acute respiratory Antibiotic misuse and overuse has emerged as infections. Therefore, Wyckoff, through a grant an important health care quality and patient from the United Hospital Fund, established an safety issue. While antibiotic usage has Antibiotic Stewardship quality improvement undoubtedly reduced mortalities caused by demonstration project in two of its primary care infections, resistance to these drugs has also sites: Wyckoff’s Medicine Clinic and Wyckoff increased. Studies show that up to 50% of Doctors. Through this project, in 2016, antimicrobial use is inappropriate, resulting in significant baseline data on patients presenting increased rates of serious infections such as with acute respiratory infections was Clostridium difficile. A recent Morbidity and established and benchmarked against 31 other Mortality Weekly Report estimated that practices across the State. In 2017 and beyond, immediate, nationwide infection prevention Wyckoff will develop Plan-Do-Study-Act quality and antibiotic stewardship interventions could improvement projects to improve provider avoid approximately 619,000 hospital-acquired prescribing, education, and behavior in infections resulting from Clostridium difficile response to acute respiratory infections. and other multi-drug resistant organisms. Wyckoff is currently involved in the Healthcare Association of New York State (HANYS) Quality Institute Antibiotic Stewardship Collaborative. We are collecting data on hospital-wide use of specific antibiotics and we will be submitting the data to HANYS. We started pilot interventions including ID-pharmacist-critical care team rounding to assure timeliness and appropriateness of antibiotic use in critical care units. The goal of this initiative is to identify and implement the most efficacious strategies to decrease over/under/mis-use of antibiotics, to decrease antibiotic use by 20%, to improve clinical outcomes and to decrease cost of care. 34 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 THREE YEAR COMMUNITY SERVICE PLAN Wyckoff Heights Medical Center has analyzed the data and has chosen to concentrate its Three Year Community Service Plan on two of the New York State Department of Health Agenda Priorities: 1. Promoting Healthy Women, Infants and Children 2. Preventing Chronic Diseases Wyckoff’s community service plan targets maternal and child health disparities identified locally among both Blacks and Hispanics, including perinatal outcomes and breastfeeding. The plan also targets chronic disease health disparities within the Hispanic population, including disparities in diabetes, obesity and breast cancer. Goal Objective Year One 2017 Year Two 2018 Year 3 2019 Promoting Healthy Improve birth outcomes Increase early access to prenatal care Increase participation in prenatal care Increase participation in prenatal care Women, Infants and disparities in birth through the Maternal and Infant Child and evidence-based prenatal care and evidence-based prenatal care and Children outcomes including preterm Health Collaborative Program interventions by 5% from baseline interventions by 10% from baseline birth, low birth weight, through increased internal through increased internal infant mortality and Provide evidence-based prenatal care communications and outreach to communications and outreach to maternal mortality. interventions for pregnant women community partners community partners including CenteringPregnancy and Baby Basics Increase the percentage of Increase institutional capacity for Increase targeted areas for improvement Increase targeted areas for improvement infants born who are Quality Improvement in Breastfeeding from baseline measurement, including from baseline measurement, including exclusively breastfed through participation in the NYC skin-to-skin vaginal births, rooming-in, skin-to-skin vaginal births, rooming-in, during the birth Breastfeeding Hospital Collaborative and the provision of education on and the provision of education on hospitalization and across feeding feeding the first year of life and reduce disparities in Continue WIC Peer Breastfeeding Improve exclusive breastfeeding rates Improve exclusive breastfeeding rates breastfeeding Program and Certified Lactation at six month and one year follow-up at six month and one year follow-up Consultant services on the Obstetrics points for mother’s participating in points for mother’s participating in unit, with ongoing support and follow- WIC WIC up by the Peer Breastfeeding program Achieve Baby-Friendly Hospital Designation Improve children’s social- Establish Healthy Steps program and Continue Healthy Steps program and Continue Healthy Steps program and emotional development, developmental specialist at the Pediatric developmental specialist at the Pediatric developmental specialist at the Pediatric child development Care Center, serving at least 100 Care Center, serving at least 200 Care Center, serving at least 300 outcomes, and reduce participants age 0-5 and their families participants age 0-5 and their families participants age 0-5 and their families disparities in developmental outcomes 35 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Reduce childhood obesity Provide FitWIC program including a Increase community participation in Increase community participation in and disparities in childhood farmer’s market incentive program, FitWIC by 5% from baseline through FitWIC by 10% from baseline through obesity healthy recipes, food demonstration and increased internal communications and increased internal communications and physical activities, such as Zumba in outreach to community partners outreach to community partners the Park. The program has an on-site community garden, where participants can learn about how to grow healthy and nutritious vegetables Increase the percentage of Through Her Breast Health First Through Her Breast Health First Through Her Breast Health First women, particularly Black Program, conduct 960 additional Program, conduct 960 additional Program, conduct 960 additional and Hispanic women over mammograms each year, including 320 mammograms each year, including 320 mammograms each year, including 320 40 years of age who receive women from the community and 640 women from the community and 640 women from the community and 640 breast cancer screening from within the medical center who are from within the medical center who are from within the medical center who are based on the most recent past due or missed their appointment past due or missed their appointment past due or missed their appointment clinical guidelines Preventing Chronic Create an environment that Institute Unidine “OH SO GOOD” Increase uptake of “OH SO GOOD” Continue to increase uptake of “OH SO Diseases – Obesity, promotes and supports Healthy Food and Lifestyle Choices menu options by 5% from baseline GOOD” menu options by 10% from Diabetes, and healthy food and beverage Program and collect baseline utilization through promotion and marketing baseline through promotion and Cardiovascular choices and physical data marketing Disease activity Institute collaborative Implement PCMH+ Project across all Increase patients with documented self- Increase patients with documented self- community-based programs Article 28 primary care sites including management goals and care plans by management goals and care plans by to increase preventive health coaches to identify patients with 5% from baseline 10% from baseline activities targeting obesity, chronic condition risk factors. Health diabetes, and coaches will work with patients to cardiovascular disease identify self-management goals and develop care plans in collaboration with primary care providers Promote and roll-out community Increase community participation in Increase community participation in outreach programs, including Senior Senior Supper Program, Culinary Senior Supper Program, Culinary Supper Program, Culinary Classes, and Classes, and Farmers Markets by 5% Classes, and Farmers Markets by 10% Farmers Markets and collect baseline from baseline through promotion to from baseline through promotion to participation data community based organization partners, community based organization partners, including Ridgewood-Bushwick Senior including Ridgewood-Bushwick Senior Citizens Council Citizens Council 36 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Offer wellness program including Increase staff and community resident Increase staff and community resident Zumba and Yoga for employees and participation in wellness program by participation in wellness program by community members 5% from baseline through increased 5% from baseline through increased internal communications and outreach internal communications and outreach to community partners to community partners Participate in collaborative awareness Increase the percentage of adults who Increase the percentage of adults who campaign “Vida Si, Diabetes No!” to had a test for high blood sugar or had a test for high blood sugar or reach Hispanic populations at high risk diabetes within the past 3 years by 5% diabetes within the past 3 years by 10% and collect baseline screening data from baseline and link individuals to from baseline and link individuals to medical care and Wyckoff’s diabetes medical care and Wyckoff’s diabetes education program education program Launch Million Hearts initiative to Increase proportion of patients in Increase proportion of patients in improve risk screening for primary care who receive primary care who receive Cardiovascular Disease and measure cardiovascular disease risk screening by cardiovascular disease risk screening by baseline screening data 5% from baseline 10% from baseline Preventing Chronic Institute Breathe Easy Asthma Team Increase the number of home visits by Increase the number of home visits by Diseases - Asthma Home Visiting Program with 10% from baseline and measure impact 20% from baseline and measure impact community partners through DSRIP on asthma emergency department visits on asthma emergency department visits and collect baseline participation and and hospital discharges and hospital discharges utilization data Increase the percentage of adults with Increase the percentage of adults with current asthma who have received a current asthma who have received a written asthma action plan from their written asthma action plan from their health care provider health care provider 37 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 FINANCIAL PROGRAM to provide healthcare to the needy is our sliding scale fee that offers discounts for patients that Financial Aid Program. The biggest challenge do not qualify for Medicaid. Patients can qualify for Wyckoff related to the provision of financial for discounts with family income levels up to aid is that Wyckoff serves an indigent and 300% of the federal poverty level. This enables underserved community. Fifty-one percent of those working poor without insurance to Wyckoff’s patients are covered under the receive healthcare that they otherwise could state’s Medicaid program and most of those opt not afford. to have their coverage administered by a Managed Care carrier. Another 3-5% of Traditionally, the hospital industry charged self- Wyckoff’s patients are completely uninsured. pay patients higher rates than the hospitals receive from government or commercial payers. Medicaid Application Program. One Wyckoff Wyckoff has instituted a discounted self-pay fee initiative to provide healthcare to the uninsured schedule to alleviate this burden. Again, this is an aggressive Medicaid application program. enables uninsured patients, regardless of Wyckoff will prescreen patients, based on financial status, to receive healthcare that they financial status, to qualify patients for the otherwise may not seek. State’s Medicaid program. If the patient is determined to be a candidate, Wyckoff will Charity Care. In 2015 Wyckoff provided to the complete the Medicaid application for the communities it serves a total of $23.2 million of patient at Wyckoff’s expense. If successful, uncompensated care in the form of charity care Wyckoff will be paid for the services provided and uncollectible accounts. This level of by Medicaid and in turn, the patient will have uncompensated care reflects the significant Medicaid coverage for future healthcare needs. financial and healthcare needs of our local community. Despite these high levels of Access to the New York State Health Exchange. uncompensated care, Wyckoff is dedicated to Wyckoff’s Medicaid office employs three providing the highest quality of care to all of our Certified Application Counselors (CAC), who are patients. trained to assist patients apply for insurance via the New York State Exchange. At Wyckoff, the Changes Impacting Community Health/Access CACs work primarily with patients who do not to Services. Recent federal healthcare reform qualify for Medicaid. The office also offers legislation and ongoing reductions in Medicare support in applying for insurance for the and Medicaid reimbursement will require community at large through referrals or walk- Wyckoff, as well as most hospitals around the ins. Wyckoff also partners with community- country, to develop a tightly integrated service based organizations to assist community model which provides for an increased members in applying for insurance via the coordination of patient care and reduces exchange, including Make the Road New York, duplicative efforts and services. System which has expertise in enrolling Spanish fragmentation among doctors, medical groups, speakers and new immigrants, and Ridgewood- outpatient centers and hospitals will need to be Bushwick Senior Citizen’s Council, who supports minimized. Wyckoff in enrolling elders and the unstably housed. Wyckoff has begun efforts to improve the integration of clinical relationships with private Discounted Self-Pay Fee Schedule. Since physician office practices in the Hospital’s patients have to be at the poverty level to primary and secondary service areas. We have qualify for Medicaid, another Wyckoff program developed a Patient-Centered Medical Home (PCMH) model of care to improve the 38 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 coordination of healthcare services provided to patients residing in these areas. We are Internal Communications and Intranet. The participating in the Brooklyn Health Information Community Service Plan will be sent out to the Exchange (BHIX) to enable compliant Wyckoff Heights Medical Center listserv which information sharing of electronic data, as well reaches all 1,500 staff members. Staff will also as the Delivery System Reform Incentive be able to access the plan through the Payment Program (DSRIP) Dashboard, which employee intranet. In addition, a link will be also enables participating providers to share posted on Wyckoff’s Facebook Page and sent patient information. Wyckoff is implementing out via Twitter. direct message communication with local private physicians to electronically send Presentations at Key Meetings. The Community continuity care documentation at the time of Service Plan will be presented at key meetings, discharge to support transitions of care. including the President’s Town Hall meeting Wyckoff’s intent is to provide an interoperable which is open to the staff and public. The Plan IT infrastructure for all of its service area will also be presented at leadership meetings healthcare providers to establish the ability to including Executive Committee meeting, share clinical information electronically. Department Managers meeting, and the Medical Board meeting. Special Programs for the Uninsured. Wyckoff offers some limited outpatient services to the Additionally, copies of the CSP will be available community free of charge, including HIV by request from the following offices and screening and biomedical prevention and STD contacts: screening and treatment. Wyckoff participates in the AIDS Drug Assistance Program (ADAP) Office of the President and CEO which provides comprehensive healthcare and Wyckoff Heights Medical Center prescription coverage to individuals who are 374 Stockholm Street uninsured or underinsured. Brooklyn, NY 11327 Zachariah Hennessey DISSEMINATING THE PLAN Assistant Vice President, Special Projects and Evaluation Website. A summary of the CSP will be available 374 Stockholm Street through the hospital’s website at Brooklyn, NY 11327 Phone: (718) 907-4952 www.wyckoffhospital.org with a prominent link E-mail: [email protected] to the full report. Community Advisory Boards. The Community Service Plan will be distributed to all key contacts at relevant Community Boards for the neighborhoods we serve. These include Brooklyn Community Boards 1, 3, 4, and 5 and Queens Community Boards 5. The Community Board Contacts are listed at the end of this section. The Comprehensive Community Service Plan will be distributed to Wyckoff Heights Medical Center’s President’s Community Advisory Council and Wyckoff’s Community Advisory Board. 39 Wyckoff Heights Medical Center Community Service Plan, 2017-2020 Community Boards Contact Information: Brooklyn Community Board 1 Queens Community Board 5 Neighborhoods: Williamsburg, Greenpoint Neighborhoods: Ridgewood, Glendale, Middle Address: 435 Graham Avenue, Village, Maspeth Brooklyn, NY 11211 Address: 127 Pennsylvania Avenue, Phone: 718-389-0009 Brooklyn, NY 11207 Email: [email protected] Phone: 718-498-5711 Chair: Dealice Fuller Email: [email protected] District Manager: Gerald A. Esposito Chair: Vincent Arcuri, Jr. Board Meeting: Second Tuesday, 6:30pm District Manager: Gary Giordano Board Meeting: Second Wednesday, 7:30pm Brooklyn Community Board 3 Neighborhoods: Bedford-Stuyvesant Address: 1360 Fulton Street, Brooklyn, NY 11216 Phone: 718-622-6601 Email: [email protected] Chair: Tremaine Wright District Manager: Henry Butler Board Meeting: First Monday, 7:00pm Brooklyn Community Board 4 Neighborhoods: Bushwick Address: 315 Wyckoff Avenue, Brooklyn, NY 11237 Phone: 718-628-8400 Email: [email protected] Chair: Julie Dent District Manager: Nadine Whitted Board Meeting: Third Wednesday, 6:00pm Brooklyn Community Board 5 Neighborhoods: East New York Address: 127 Pennsylvania Avenue, Brooklyn, NY 11207 Phone: 718-498-5711 Email: [email protected] Chair: AT Mitchell Board Meeting: Fourth Wednesday, 6:30pm 40