Practice Settings

Comprised of three acute care hospitals with 2130 licensed beds, 111,563 discharges in 2015, 1.9 million patient encounters, 6400 employed physicians, an additional 2000 physicians who comprise the faculty of the Yale School of Medicine, 20,000 employees, and $3.6 billion in revenue, the Yale-New Haven Health System is one of the largest in the country. Although located in a small Northeastern state, the health system serves a geographically and socioeconomically diverse patient population: the racially, ethnically, economically diverse city of New Haven, the underserved, largely African-American city of Bridgeport, and the affluent, large White city of Greenwich.

CHIRAL is a joint venture of Yale School of Medicine (YSM) and Yale-New Haven Hospital (YNHH) that brings together physicians, nurses, industrial engineers, communication experts, informatics specialists, sociologists, simulation researchers, clinical researchers and administrators, creating a dynamic learning environment to improve patient safety. It will expand existing, highly productive collaborations between YNHH and a group of investigators who have conducted pioneering work in communications, transitions, quality of care andpatient safety. CHIRAL focuses on an error-prone moment in healthcare: transitions of care. CHIRAL investigators are using mixed methods approaches to develop and implement a variety of strategies to ensure safe transitions of care, particularly in and out of intensive care units.

The Yale Transdisciplinary Collaborative Center for Health Disparities Research Focused on Precision Medicine (YALE-TCC) is a Region II coalition ofresearch institutions (n=5), stakeholder member organizations (n > 80 individuals representing >30 organizations) focused on African descent and Hispanic populations living in the U.S. Virgin Islands and Puerto Rico. The YALE-TCC proposes a research portfolio that combines different types of data to improve our ability to identify who is at risk for hypertension (HTN) and type 2 diabetes (T2D) sooner than we can now. The YALE-TCC also supports pilot and demonstration projects. Through the coordinated activities of the YALE-TCC, the ultimate goal is to identify and test culturally relevant and low resource interventions to reduce the population burden of HTN and T2D and to inform clinical care delivery to individual patients at high risk for these diseases and their consequences. This new center is led by Marcella Nunez-Smith, MD, Associate Professor of Medicine and Public Health at Yale, and a mentor for YSIS.

The mission of the New Haven Department of Health is to ensure and advocate for the health and well-being of all New Haven residents. Composed of 21 divisions, including programs in asthma control, epidemiology, preventive medicine, school-based programs, tobacco control, and tuberculosis control, the Departmenthas 95 employees and an annual budget of $15 million. Since 2015, the Department has been led by Brian Kennedy, MD, PhD, MPH, a Yale-trained preventive medicine physician who has launched several new initiatives. A key interest of Dr. Kennedy’s is improving the respiratory health of children. To that end, the Department has begun a summer camp for children with asthma that incorporates the Easy Breathing curriculum and launched a Healthy Homes program to identify asthma triggers.

These programs are also spurred by New Haven’s selection as one of six Innovator Cities and Counties chosen to participate in the Healthiest Cities & Counties Challenge. Sponsored by the American Public Health Association, Aetna, and the National Association of Counties, the Challenge will award $1.5 million in prizes to cities and counties that build cross-sector teams around locally important health issues. For New Haven, YSIS and related activities will contribute to the formation and work of these teams.

Junta empowers the Latino and low-income communities of Fair Haven (a neighborhood in the eastern portion of New Haven) to take control of their economic and social well-being, while civically engaging in the community. Junta promotes a culture of community involvement and advocacy through its programs and initiatives, which include health literacy, adult education, children’s programs, economic development, family management, immigrant rights and cultural appreciation. Junta is a diverse organization, representing over 10 countries including Argentina, Mexico, the Dominican Republic, Ecuador, El Salvador, Honduras, Panama, Peru, Puerto Rico, and the United States.

PA-NH brings the Greater New Haven community together to identify underserved patients with urgent medical needs and connect them with donated medical care and services generously provided by over 300 physician volunteers across 28 specialties, Yale-New Haven Hospital (YNHH), and many other participating providers and partners. At the core of the program are Patient Navigators who help patients navigate the health care system, identify and address barriers to care, and ensure access to needed care in a timely fashion. Project Access and Yale-New Haven Hospital were awarded the CT Hospital Association and CT Department of Public Health’s 2014 CT Hospital Community Service Award. Since opening in September 2010, PA-NH has served nearly 1000 patients and provided over $16 million in donated care to those in need. PA-NH patients have reduced wait-times and increased show rates for medical appointments –19 days vs. 6 weeks-1 year in local hospital specialty clinics and 3% vs. 34%, respectively. Patients also report improved health and quality-of-life, increased ease of getting care, and high program satisfaction when surveyed one year after enrollment. PA-NH results have been presented at several national conferences, including the Annual Meetings for the American Public Health Association, AcademyHealth, Communities Joined in Action, and the Society for Academic Emergency Medicine. Dr. Spatz, a YSIS mentor, is a member of the board of Project Access.

Columbus House is the largest provider of services for the homeless community of New Haven. Its mission is to serve people age 18 or older who are homeless or at risk of becoming homeless by providing shelter and housing and by fostering personal growth and independence. Columbus House opened in 1982. To accomplish its mission, Columbus House relies on government grants as well as contributions from the private sector including businesses, foundations and individuals. Yale-New Haven Hospital is an important partner of Columbus House.

One program of note is the medical respite service. This 12-bed unit, opened in 2014, offers an alternative to hospitalization for homeless adults with acute medical conditions like pneumonia or cellulitis that might otherwise require hospitalization. The respite unit is staffed 24 hours daily, has a visiting nurse, access to providers, case management, and transportation. Referrals come directly from the Yale-New Haven Hospital or the West Haven VA. Respite programs have been shown to reduce future hospitalizations and readmissions, with excellent health outcomes. Much of the scholarship in respite programs and the healthcare needs of the homeless was done at Yale and Columbus House by Kelly Doran, MD, MHS, a former Robert Wood Johnson Clinical Scholar and mentee of Dr. Bernstein’s and Dr. Curry’s, who is now at New York University. YSIS Scholars will have the opportunity to implement additional respite-related medical programs.

DataHaven is a partner of the National Neighborhood Indicators Partnership, a collaborative national effort by the Urban Institute in Washington, DC and approximately 40 local partners to further the development and use of neighborhood information systems in local policymaking and community building. DataHaven is also involved in many initiatives to further the usability of high-quality data at a local and statewide level. Its largest current program is the DataHaven Community Wellbeing Survey, which produces information on quality of life, public health, economic development, and civic vitality for over 100 partners throughout Connecticut and sections of nearby states. Survey results and new reports, including an updated and significantly expanded Community Index, are being released throughout 2016. Other recent work includes developing comprehensive community indicators within Fairfield County and Greater New Haven, evaluating the livability for older adults in Connecticut, measuring neighborhood income inequality in Connecticut, and publishing special data-driven reports on civic health, early childhood education, the impact of immigration, how transportation influences job access, and other topics at the statewide, regional, and local levels. Emily Wang, MD, MAS, a mentor on this application, serves on the Board of DataHaven.