Blog September 07, 2018

Healthcare Systems and the Community in Partnership

By Tara Cortes

Preparation of the healthcare workforce to keep people at the highest level of wellness as they age is a great challenge in US where 10,000 people turn 65 every day and most people over the age of 65 have at least one chronic disease. The Hartford Institute for Geriatric Nursing at NYU Meyers College of Nursing is partnered with Montefiore Health System and RAIN (Regional Aid for Interim Needs) in the HRSA funded Geriatric Workforce Enhancement Program (GWEP). This initiative is designed to prepare an age sensitive workforce and to break down the silo of the primary care provider’s office and deliver primary care as a continuum across the community using available resources to enhance the wellness of the aging population. A long term goal of this initiative is to help older people be independent in the community as long as possible with knowledge about managing chronic disease and putting into action behaviors to enhance health.


The traditional primary care workforce of physicians, nurses, social workers and other health professionals is just not adequate to meet the needs of the growing older population. It is necessary to educate the existing workforce and those students who will be entering the workforce about the complex care required by older adults. Through this GWEP we have educated over 1000 health care professionals on the unique care of older adults living in the community. The learners have included physicians, residents, medical students and fellows, nurses and social workers in home care, primary care, case management and community based organizations.  In addition, we have educated over 1200 home health aides on caring for patients with dementia.


And, we must educate a non-traditional workforce in community settings and empower people with knowledge about their own health and management of chronic diseases. A cornerstone of this GWEP has been the launch of a group of volunteers who have formed the Bronx Health Corps.  Of the more than 90 volunteers trained for this program, 63 qualified as health ambassadors to educate seniors in the community on chronic disease management and health behaviors.  In a s sampling of the more than 1,300 seniors educated through this program, more than 70% have reported that they have changed their behavior and more than 75% have said they perceive their health as “better”.  An exercise class led by two health ambassadors from the Bronx Health Corps was aired on NY1 recently. To view it please click this link.

We must forge partnerships between clinical systems including primary care practices and community -based organizations (CBOs) and use those CBOs as vital resources to the neighborhoods in which they are located. And, we must advocate for communication systems which enable the transfer of meaningful information from healthcare providers to community based organizations with feedback to the healthcare provider. Through this GWEP we have developed a HIPPA compliant digital system to communicate between CBOs and primary care practices. Patients can be referred for transportation, housing, nutrition, education and social services and feedback can be given to the primary practice on the meeting of goals in the plan of care.  Empowering the workforce with age specific knowledge and the community with knowledge and resources to improve health literacy and decrease fragmentation of healthcare will lead to an increase in population health, decrease the need for costly acute care resources, improve outcomes and increase provider satisfaction.

Tara Cortes is recognized for her distinguished career spanning executive leadership, nursing education, research and practice. She is currently the Executive Director of the Hartford Institute for Geriatric Nursing, and a Professor in Geriatric Nursing. Dr. Cortes has provided significant contributions to advance the health of people, particularly those with limited access to the health care system. Importantly, she has developed collaborative models with advanced practice nurses and physicians in traditional as well as nontraditional settings to enhance the care of the American elderly population.  Click here for more information on Tara Cortes.