NYC Care: A Large Health Care Access Program for Uninsured New York City Residents.

CONTEXT: Millions of people living in the United States are excluded from health insurance due to income or immigration status. These 2 groups are more likely to lack access to health care or a regular source of care. PROGRAM: NYC Health + Hospitals is addressing this need with NYC Care, a health care access program. The program is designed to be the single point of access for uninsured care citywide and includes a membership card, a 24-hour customer service line, and direct access to primary care medical homes. Health care is coordinated across NYC Health + Hospitals using integrated electronic referrals and a medical record system. IMPLEMENTATION: The program uses a single enrollment process across safety net health care resources of NYC Health + Hospitals. A 24-hour call center was established to answer questions, make primary care appointments, and make warm handoffs to enrollment staff. Once eligibility is confirmed and patients are enrolled, they are mailed a membership card, a member handbook, and offered a primary care appointment. A multipronged public awareness campaign including citywide, multilingual marketing and outreach via community-based organizations was essential to build trust. OUTCOMES: NYC Care had 119 203 members at the end of June 2023. Fifty-eight percent had not seen a primary care doctor in the NYC Health + Hospitals system in the prior 36 months. In total, 76 439 had completed 1 or more primary care visits; 53.1% of enrollees with diabetes had improved hemoglobin A 1c , and 73.4% of enrollees with hypertension had improved blood pressure control after 6 months of enrollment. DISCUSSION: NYC Care demonstrates that municipalities can improve access to care for the uninsured by simplifying steps to affordable health care services, connecting patients directly to patient-centered medical homes, and improving the patient experience. A comprehensive public awareness campaign is also crucial.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization.

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Upper Gastrointestinal Endoscopy with biopsy in paediatric feeding disorders.

AIM: Our aim was to evaluate upper GI pathology found endoscopically among children seen in a GI feeding clinic for persistent feeding problems compared with controls. METHODS: Esophagogastroduodenoscopy biopsy results were examined among two cohorts of children. The first group included 86 children evaluated in a gastroenterology feeding clinic for paediatric feeding disorders. A comparison was made with an age-matched control group of 86 children referred for endoscopy for conditions other than disordered feeding. RESULTS: In the feeding cohort, 57% had abnormal endoscopy biopsies. These included 30% with microscopic esophagitis and 15.1% with eosinophilic esophagitis (EoE). Among the controls, 53% had abnormal biopsies, which included 26% with microscopic esophagitis and 8% with eosinophilic esophagitis. The statistical comparison between groups included p = 0.98 for microscopic esophagitis and p = 0.15 for eosinophilic esophagitis. CONCLUSION: Results demonstrated similar prevalence of abnormal endoscopy biopsies and microscopic esophagitis in both groups. The incidence of eosinophilic esophagitis in the feeding group triples that of previous reports and nearly doubles controls. Our findings suggest paediatric feeding disorders which do not resolve may warrant investigation by upper endoscopy.

Successful gastrostomy tube weaning program using an intensive multidisciplinary team approach.

OBJECTIVES: The present study evaluated the effectiveness of a multidisciplinary intensive inpatient model for gastrostomy tube (GT) weaning. METHODS: A retrospective chart review was completed on 30 GT-dependent children, ages 3.9 (±1.4) years, admitted to the inpatient feeding program (length of stay 19 days) from May 2009 to December 2011. Administered GT calories were decreased on admission by an average of 73% from home regimen. Patients were offered 3 meals and 2 to 3 snacks/day, including 3 intensive feeding therapy sessions (Monday to Friday), along with psychosocial support, nutrition guidance, and behavioral therapy. Daily calorie counts and weights were recorded. Patients returned for a postdischarge feeding evaluation at an average of 4 months and a clinic visit at 1 year. Data were analyzed using paired samples t tests. RESULTS: Before admission, patients received 69% (±25) of goal calories by GT and 22% (±19) of goal calories orally. During admission, average caloric intake by mouth as a percentage of goal increased during the course of weeks 1, 2, and 3 (68%, 77%, and 82%, respectively), with a statistically significant increase between weeks 1 and 2 (P = 0.001) and 1 and 3 (P = 0.011). At discharge, 90% had discontinued GT feedings. Average percent weight change during admission was 0.2% (±4). At 1 year follow-up, 83% remained successfully off GT feedings. CONCLUSIONS: Children who are GT dependent can be weaned off GT feedings during a 3-week admission using a multidisciplinary feeding model. The therapeutic gains were maintained at 1 year postdischarge.

Advancing Lifestyle Medicine in New York City's Public Health Care System.

Chronic diseases are the leading cause of death and disability in the United States, and much of this burden can be attributed to lifestyle and behavioral risk factors. Lifestyle medicine is an approach to preventing and treating lifestyle-related chronic disease using evidence-based lifestyle modification as a primary modality. NYC Health + Hospitals, the largest municipal public health care system in the United States, is a national pioneer in incorporating lifestyle medicine systemwide. In 2019, a pilot lifestyle medicine program was launched at NYC Health + Hospitals/Bellevue to improve cardiometabolic health in high-risk patients through intensive support for evidence-based lifestyle changes. Analyses of program data collected from January 29, 2019 to February 26, 2020 demonstrated feasibility, high demand for services, high patient satisfaction, and clinically and statistically significant improvements in cardiometabolic risk factors. This pilot is being expanded to 6 new NYC Health + Hospitals sites spanning all 5 NYC boroughs. As part of the expansion, many changes have been implemented to enhance the original pilot model, scale services effectively, and generate more interest and incentives in lifestyle medicine for staff and patients across the health care system, including a plant-based default meal program for inpatients. This narrative review describes the pilot model and outcomes, the expansion process, and lessons learned to serve as a guide for other health systems.

The San Francisco Community Vital Signs: using web-based tools to facilitate the mobilizing for action through planning and partnerships process.

A coalition of local public health system stakeholders in San Francisco developed a community assessment and strategic planning tool, the San Francisco Community Vital Signs (SFCVS). The SFCVS builds on the Mobilizing for Action through Planning and Partnerships (MAPP) model by incorporating Internet-based technology into local public health system evaluation and strengthening. This article describes the overlap between the SFCVS and MAPP processes, the manner in which information technology facilitated the SFCVS process, and a template for infusing a Web-based platform into the MAPP model. Internet-based applications helped to implement many (16 of 41; 39%) of the components of the SFCVS process. Of these 16 process measures, the majority (10; 63%) required the use of Web-based technology. The SFCVS demonstrates that a MAPP-like process can leverage the Internet to augment the functionality of public health activities.

Assessing and increasing patient panel size in the public sector.

CONTEXT: Panel management is a central component of the primary care medical home, but faces numerous challenges in the safety net setting. In the San Francisco Department of Public Health, many of our community-based primary care clinics have difficulty accommodating all patients seeking care. OBJECTIVE: We evaluated patient panel size in our 7 clinics providing cradle-to-grave primary care services to more than 25,000 active patients. DESIGN: We adjusted panel size for age, gender, diagnoses, homelessness, and substance abuse; set related policies; and assessed the effects on our clinics. On the basis of our previous data and targets set by other safety net providers, we established a minimum of 1125 patients per full-time paid primary care provider (ie, full-time equivalent [FTE]) in April 2009. We calculated the target panel size each clinic would have if all their providers reached the minimum panel size goal and compared it with the panel size attained by the clinic. RESULTS: Nine months after establishing panel size policy, providers reached 82% of the aggregate target panel size. Five of the 7 clinics increased their adjusted panel size per FTE in the range of 2% to 23%. Two data-oriented and innovative clinics with some of the highest adjusted panel sizes per FTE largely maintained their panel size. Two clinics that had the lowest adjusted panel size per FTE realized a 23% and 8% respective gain; both clinics reduced barriers to new patient appointments. Two clinics acquired new providers and experienced a concomitant drop in panel size per FTE while the new clinicians expanded their panels. One of these clinics had difficulty managing high no-show rates and creating effective appointment templates. CONCLUSIONS: Routine data generation, review of data with administrators and providers, data-driven policies and panel size standards, and interventions to bolster team-based care are important tools for increasing capacity at our primary care clinics.

Prediction model to maximize impact of syphilis partner notification--San Francisco, 2004-2008.

BACKGROUND: Syphilis cases increased 55% in San Francisco from 2007 (n = 354) to 2008 (n = 548). The San Francisco Department of Public Health interviews syphilis patients to identify sex partners needing treatment, but interviewing resources are limited. We developed and validated a model to prioritize interviews likely to result in treated partners. METHODS: We included data from interviews conducted from July 2004 through June 2008. We used multivariate analysis to model the number of treated partners per interview in a random half of the data set. We applied the model to the other half, calculating predicted and observed proportions of partners successfully treated and interviews conducted if limiting interviews by syphilis patient characteristics. RESULTS: In 1340 patient interviews, 1665 partners were named; of those, 827 (49.7%) were treated. Ratios of treated partners were significantly higher among patients aged <50 years, compared with >or=50 years (ratio 1.4; 95% confidence interval [CI], 1.0-1.9); patients with primary/secondary syphilis, compared with early latent (ratio 1.4; 95% CI: 1.1-1.8); and patients diagnosed at the municipal sexually transmitted disease clinic, compared with elsewhere (ratio 1.7; 95% CI: 1.4-2.1). Limiting interviews to patients aged <50 years would reduce interviews by 14% and identify 92% of partners needing treatment. Limiting interviews to primary/secondary syphilis patients would reduce interviews by 35% and identify 68% of partners needing treatment. CONCLUSIONS: Our model can provide modest efficiencies in allocating resources for syphilis partner notification. Health departments should consider developing tools to maximize impact of syphilis prevention and control activities.

The effectiveness of patient-delivered partner therapy and chlamydial and gonococcal reinfection in San Francisco.

BACKGROUND: Patient-delivered partner therapy (PDPT) has been evaluated in randomized trials. No analysis has examined the impact of PDPT once implemented programmatically. METHODS: We examined the association between receiving PDPT and Chlamydia trachomatis and Neisseria gonorrhoeae reinfection within 1 year in patients diagnosed at San Francisco City Clinic between October 31, 2005 and March 31, 2008. Propensity score modeling was used to control for the difference between persons who did and did not receive PDPT. RESULTS: There was no significant difference between patients who received PDPT and those that did not in the crude cumulative risk for repeat infection with C. trachomatis or N. gonorrhoeae. Using propensity score analysis, the adjusted relative risk was 0.99 (0.86-1.14) for chlamydial reinfection and 0.90 (0.72-1.11) for gonococcal reinfection. Further analysis looking at men who have sex with men, men who have sex with women, and females showed no significant reductions in relative risk of reinfection for C. trachomatis or N. gonorrhoeae in these sub populations. CONCLUSIONS: Continued evaluation of PDPT on reinfection rates in real world settings as well as cost-effectiveness analyses of PDPT are needed to assess this alternative method of partner treatment.