The Children’s Hospital/Montefiore Medical Center

Member of the Council badgeThe New York Children’s Health Project (NYCHP, a program of Community Pediatric Programs of The Children’s Hospital at Montefiore Medical Center/Albert Einstein College of Medicine, offers homeless families and street youth access to an enhanced medical home at 14 locations throughout New York City. Founded in 1987, NYCHP is one of the original grantees under the McKinney Act. NYCHP has grown from one custom-designed mobile medical clinic with a dedicated pediatrician and driver/registrar to a fleet of four mobile medical clinics and a mobile dental clinic, along with three shelter-based clinics and a full-time clinical hub site, staffed by highly skilled pediatric and family medicine providers, nurses, mental health and dental professionals, nutrition/health educators and support personnel. The NYCHP’s innovative service delivery model is designed to decrease the significant barriers to care experienced by the target population.

Services

NYCHP has grown from one custom-designed mobile medical clinic with a dedicated pediatrician and driver/registrar to a fleet of four mobile medical clinics and a mobile dental clinic, along with three shelter-based clinics and a full-time clinical hub site, staffed by highly skilled pediatric and family medicine providers, nurses, mental health and dental professionals, nutrition/health educators and support personnel. The NYCHP's innovative service delivery model is designed to decrease the significant barriers to care experienced by the target population. In January 2011, NYCHP attained the highest recognition level ("Advanced/Level 3") as a Patient Centered Medical Home from the National Committee for Quality Assurance (NCQA).   NYCHP's medical team attends to the fundamental, as well as the unique, health care needs of children, adolescents and adults for the duration of their homelessness, in addition to while formerly homeless families transition to permanent medical care in the community. Services range from well-child check ups, immunizations and physicals to asthma, hypertension and other chronic disease management to screening for lead exposure, vision/hearing, and cancer or HIV counseling and testing*to name a few. The program's bilingual mental health team*made up of a clinical psychologist Meeting Form and two social workers*provides counseling and referral, substance abuse prevention/referral, case management, and entitlements assistance. Other NYCHP services include nutrition assessment and counseling, women's health care, subspecialty referral management, and health education. Community Pediatric Programs also operates a new, two-chair mobile dental clinic to directly provide full-time oral health services to homeless patients, who typically have virtually no, or very limited, access to dental services. Dental services include: preventive care, including exams, cleaning, fluoride, sealants, and oral health education; digital x-rays; fillings/dental work; and referrals for extensive dental care. The NYCHP provides pharmacy services through accounts maintained at selected local pharmacies and covers the cost of medications not covered by Medicaid. Patients can reach medical providers 24 hours a day, seven days a week through a toll-free number. All NYCHP sites are connected by a single electronic health record (EHR) system.   24 hour emergency on-call, Asthma treatment, Basic Needs, Behavioral Health Care Services, Blood Pressure Monitoring, Cancer Screening, Case Management/Social Services, Child Development Services, Chronic Bronchitis/Emphysema, Contraceptives (issued w/counseling), Dental Care, Diabetes Testing/Care, Domestic Violence services, Electronic Medical Records, Family Planning, Flu Vaccinations, Health/Nutritional Education, HIV/AIDS screening/education, Immunizations, Interpretation services, Labs, Medications Prescription, Mental Health Counseling, Mobile Medical Services, OB/GYN, Outreach, Pediatrics, Pharmacy, Physical Exams, Primary Health Care, Referrals for Specialty Care, Sexual Abuse Support Services, Specialty Care, STD Testing, Street Outreach, Substance Abuse Treatment, TB screening/education, Tobacco cessation, Transportation Services, Urgent Care, Well Child Check-ups

Linkages

NYCHP’s Referral Management initiative improves access to subspecialty care and uses a team of family health workers (referral managers) and an active transport service to facilitate this process. NYCHP referrals provide linkages with Montefiore Medical Center, many other hospitals for emergency and other specialized services, and social services agencies, including early intervention programs, domestic violence services, drug treatment programs, legal services, WIC and food stamp programs, emergency food, and public assistance and Medicaid offices across the city.

Statistics

Estimated homeless population: 113,000

Patients served: 3,761