New York and Presbyterian Hospital, New York, NY

STaR Project (Stimulating Transformation of Technology and Team structure to Reach PLWH)

The Comprehensive Health Program of New York Presbyterian/Columbia (NYP-CHP) is a Ryan White-funded bilingual Patient-Centered Medical Home that emphasizes sexual health, hepatitis management and HIV care and primarily serves communities of Upper Manhattan and the South Bronx. Through resource transformation, their STaR Project will increase NYP-CHP’s patient capacity, improve efficiency and optimize patient outcomes via three main initiatives. First, NYP-CHP staff will be restructured into clinical care teams that are united in purpose to care for shared panels of patients. Secondly, team coordination and enhanced linkage and retention will be implemented through a dedicated clinical care coordinator and outreach worker. Third, innovative health information technology will be used to support population and individual level care coordination efforts and practice efficiency. NYP-CHP’s electronic medical record system will be linked to the local Regional Health Information Organization (RHIO) and enhanced to provide the care teams with novel panel management tools capable of driving practice transformation.

NYP-CHP staff will be organized into 4 coordinated teams, each led by social worker-registered nurse co-captains to manage a shared panel of patients. The team approach will enhance communication and permit safe, supervised task shifting which will increase patient capacity for clinicians. Each team will consist of a multidisciplinary group that embodies the medical home model including a social worker and registered nurse, clinicians, a care coordinator, a behavioral health specialist, a linkage and retention specialist, and a peer educator. The outreach expert will provide cross-setting patient support at inpatient, ambulatory care and community sites). A dedicated registered nurse clinical care coordinator will oversee clinical aspects of the team model and work closely with the Project Director to coordinate team meetings and use of STaR HIT for weekly team meetings.