Within the New York City metropolitan area, hospitals and health systems are tasked with addressing a wide range of social and economic factors that affect people's overall health — including obesity, food insecurity, mental health and patient access. In response, they have rolled out efforts such as screenings, telehealth services and a pilot mobile food market to effect change citywide.
Here, leaders from New York hospitals and health systems spoke with Becker's Hospital Review about the most pressing public health concern facing their organizations and how they're addressing it. Here is an overarching look at public health — in these leaders' own words.
Scott Friedman, MD, chief of the division of liver diseases, dean for therapeutic discovery, at Icahn School of Medicine at Mount Sinai
The top challenge
Obesity and liver disease are on the rise, and they disproportionately affect middle and lower-income individuals who don't have access to exercise and healthy diets, and who also may have genetics that place them at heightened risk for developing fat and inflammation in their liver. [At the same time], managing the rising cost of healthcare and the shrinking margins and reimbursement and what those effectively do is threatening the health of our communities and our patients and those who should be our patients.
How your organization is responding
We have a growing commitment to population health and changing the paradigm, so we are keeping patients well and out of the hospital and avoiding disease rather than waiting until they get sick when the cost of their care is much higher and the outcomes are poorer. We're increasingly committed to maintaining wellness and reducing the ravages of advanced disease of any type.
In my area of liver disease, we have a growing program to screen at-risk communities both for viral hepatitis, and increasingly for obesity-related liver disease, known as non-alcoholic fatty liver disease. And we have connections to different healthcare groups. For example, we work with our diabetes practices because those patients are high risk. We work with bariatric surgery programs and also primary care [caregivers], who are on the cutting edge or leading edge of detecting obesity-related liver disease.
It's also worth remembering that the prevalence of obesity is astonishingly high, and with that comes complications: Type 2 diabetes, hyperlipidemia as well as liver disease. There are no approved therapies yet for the liver disease that's associated with this state of obesity. We really have a long way to go both in identifying patients who have a disease and don't know it, but more importantly bringing effective treatments to them.
Fritz Francois, MD, CMO of NYU Langone Health
The top challenge
Mental health. When one looks at what we have addressed not only in the city, but certainly across the United States, and you look at the curbs in terms of improvement, we've made strides in cardiovascular disease. We have made strides in cancer. However, we still struggle when it comes to mental health, which remains up there in terms of a significant issue. Certainly, it plays a role in a number of health disparities in various communities. There are a number of reasons for this, but I identify that as the key challenge we face right now.
How your organization is responding
We're addressing it in a multipronged fashion because what informs this includes the recognition that individuals might come in for what appears to be a different reason, but the underlying issue is mental health. Case in point: substance abuse. We have an expansive screening process when patients come in to allow us to detect alcohol and opioid use, and we've rolled out a new tool that allows us to do that. Moreover, this type of screening also allows us to screen for depression and suicidality. We have expanded the availability of psychiatry, substance abuse, and medical consults to provide support for these patients when they might be present with an apparent primary diagnosis, whereas the real driver is mental health.
We also can manage patients who might be considered medically complex but have a mental health issue that can best be cared for in our voluntary inpatient unit. That wasn't done before, but we realized that this is very important because of what we were seeing in terms of patients coming in with these diagnoses. This allows them to get the comprehensive care they need and the benefit from being on that special unit. We also have had an opportunity from a system perspective to compare notes and bring our psych teams together to review the tools we have available. Ultimately, we ensure the way we're managing patients is comprehensive in terms of these tools and protocols, while making sure patients are followed up closely once they're discharged.
We also recognize our staff need support in terms of the stress they may be under. Their wellness is something we've been addressing to reduce the stress we know can inform depression and anxiety. When there's an adverse outcome, nurses and physicians might need an avenue to deal with how it impacts them. We created a way for them to connect with their peers to begin to provide that support. If it's clear they need additional support, then a referral can be made to a mental health professional. We've also been keeping a close eye on adolescents and the impact of social media on their mental health. Our team of child psychiatrists have been working hard on providing some novel approaches to deal with this issue.
Ram Raju, MD, senior vice president and community health investment officer of Northwell Health
The top challenge
Food insecurity. We believe chronic disease management of our patients will not get better unless we address the food issues with it. Twelve percent of people who live in Northwell's service area are in a food desert, defined by U.S. Department of Agriculture as no fresh food or groceries available within their vicinity of five miles. To improve outcomes for diabetes, high blood pressure and obesity, we are focusing on that.
How your organization is responding
We said we will not try to compensate for the food insecurity by giving more medication. That means if diabetes is not under control, and providers automatically assume it is due to medication [dosage or type], that may not be true. The medication may be adequate, but the patients are not able to eat properly because they live in an area where there is not a viable grocery store or fresh food. The only viable eating available to them is fast food. We said we are not going to let our providers compensate for the food insecurity by more medications. In every hospital we want a food pharmacy.
We have [food pharmacies] in two of our hospitals, and in the next four years we want to put food pharmacies in all 23 of our hospitals. We want to send a clear message to our patients and our community that the clinical pharmacy has the medications, [and] the food pharmacy has fresh food and healthy food. When the patient is discharged, we give them a food prescription. They get a three-day supply of fresh food to take home. For people who are not able to cook, we work with a community-based organization called God's Love We Deliver, [where] we basically deliver medically tailored food for our patients.
We also sponsor farmer's markets, and by hiring chef Bruno Tison, we became the first and only health care organization in the United States to hire a Michelin Star chef. He is creating food in all of our hospitals that supports well-being by using less salt and sugar while avoiding saturated fat and minimizing frozen food and canned goods. [Overall], as a wellness organization, we believe the only way to make a substantial and lasting difference in the health of the people in our community is by tackling some of the nonclinical factors that are holding them back.
Dave A. Chokshi, MD, vice president and chief population health officer of NYC Health + Hospitals
The top challenge
When we take care of patients in the clinic or when we make rounds in the hospital, we have this expression of "seeing patients." But I think our most pressing challenge is also to focus on the patients we do not see. Patients for whom maybe fear related to immigration status or racism or the fact that they have a job or childcare that makes it difficult for them to access care, end up not seeking care or at least not seeking care until it's a crisis. We're always trying to focus on patients we do not see and thinking about how to improve our access points, pushing further into patients' neighborhoods and into their homes. Ensuring the immigrant patients we take care of feel welcomed at our healthcare facilities, and doing things to recognize that sometimes the social factors that underlie illness are just as important as the medicine we're prescribing them.
How your organization is responding
A lot of the solutions are unified under a population health approach. We think of population health as a proactive approach to addressing avoidable human suffering, and the idea we want to link patients to care before their illness has gotten to a point where it's affecting their quality of life. [It] is something we try to bake into every program and service we offer. An example of this is the work we're doing to ensure investment in primary care. But not just any primary care. Primary care where we're also trying to address behavioral health issues [and] unmet social needs, along with what people may traditionally think of as the responsibility of healthcare to take care of a physical health. We're trying to build that approach of investing in primary care across our system. It also underlies innovative things we're doing. For instance, NYC Care, which is a program that enables access to primary care for people who don't have other sources for health coverage.
Paul Dunphey, senior vice president and COO, NewYork-Presbyterian Allen Hospital & Ambulatory Care and Community Health Network
The top challenge
NewYork-Presbyterian's Division of Community and Population Health conducts a comprehensive community needs assessment every three years, most recently completed in 2019, to increase our understanding of the health and social needs of the communities we serve. Chronic disease persists as one of the most pressing public health issues in New York, and is an issue NewYork-Presbyterian is faced with across our network and the diverse communities we serve. Chronic diseases such as asthma, chronic obstructive pulmonary disease, diabetes and heart disease are among the leading causes of death and disability in the state, and yet, they are also among the most preventable.
How your organization is responding
In line with the New York State Department of Health Prevention Agenda 2019-2024, NewYork-Presbyterian's efforts to address chronic disease emphasize prevention and education, as well as access. Improving nutrition and food security is key to our prevention efforts and we have programs to help address these issues, particularly in Northern Manhattan, where more than 70 percent of residents identify as Hispanic and have encountered cultural, social and language obstacles to care. For example, our obesity prevention program, CHALK (Choosing Health & Active Lifestyles for Kids) aims to lower the prevalence of childhood and adolescent obesity in Northern Manhattan by collaborating with schools and community-based organizations to establish an environment where healthy lifestyles become vital components of the lives of all families. In partnership with the West Side Campaign Against Hunger, a nonprofit that works to alleviate hunger, we launched Food FARMacia, a pilot mobile food market for at-risk members of the community. The market is open every other Tuesday, rain or shine, and families take home between 25-30 pounds of food at each visit. A nutritionist is also on hand to provide cooking demos using ingredients available that day. Our hope is to expand this across the communities we serve in Brooklyn, Queens and Westchester.
When we think about social determinants of health, access also plays a key part. In an effort to extend our services beyond the hospital and clinic settings and enhance access to treatment, NewYork-Presbyterian is expanding and investing in telehealth services. We began piloting telehealth services across primary care, specialty care and behavioral health settings. This has enabled us to reduce length of inpatient hospital stays, as well as avoidable trips to the emergency department, ultimately improving outcomes for our patients with chronic conditions. By shifting the model of care delivery, we can increase incremental access and meet our patients where they are — in our practice sites, in their homes, and in the community.
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