The NYP Community Health Outreach Worker Program

and Diabetic Case Manager Program

212-342-1618 fax 212-342-6049

"Community health workers are specially trained community workers who serve as a bridge between the community members and the health care and social services systems. Their duties center on preventing diseases and minimizing the impact of existing diseases through health advising, social service care coordination, client intake and orientation, and outreach."

Please refer by filling out a regular NYP referral form and faxing to number above, you can also call referral line.  Please state clearly the objective for the home visit referral (i.e. check medications, provide diet counseling, assess patient safety...), inform your patient of the purpose of the visit, and provide current patient telephone number and address. Please also provide your own contact number and mailing address.  A full assessment report will be return to you.

Reasons to Refer (General)

• No show rate greater than 2 in six month period
• Non-compliance that adversely affects the person's health
• Post hospital discharge
• Greater than 2 ED visit in 6 months

Diabetes

• Newly diagnosed diabetics
• Reinforcement of treatment plan
• home assessment/food habits, lifestyle, family members
• Greater than threee Ed visits for elevated blood sugar in a six month period
• referral forms for DM CHOWP Case Manager, this info may also be emailed

Asthma

• frequent visits to the site> than three in six month period
• moderate to severe asthma
• new asthmatics
• prior history of 2 or more exacerbation in the practice within the past year
• greater than two ED visits for asthma in the past 6 months

Obesity/overweight

• Morbidly obese BMI 40 (Child)
• Mobidly obese 40 (Adults with co-mordiity)

Cardiovascular/CHF/High BP

• Uncontrolled HTN
• Medication Review
• Adherence/Compliance
• Visits to ED greater than 3
• Post Admission
• Newly diagnosed CHF

Geriatrics

• Home assessment