N.Y. Learning Collaborative to Address Chronic Disease Disparities

A new learning collaborative is seeking to tackle disparities in chronic disease management in New York City, with a strong focus on including patient input in program design. 

Around 40 percent of New Yorkers suffer from at least one chronic condition—such as heart disease or diabetes—and together these diseases account for more than 40 percent of premature deaths citywide. Alarmingly, stark disparities in the prevalence and outcomes for these chronic conditions still exist across racial and ethnic groups, income brackets, and other demographic factors. 

With the 24-month initiative, Improving Outcomes for All: Closing Gaps in Chronic Disease Management, United Hospital Fund (UHF) is partnering with a group of primary care practices to address inequities in the treatment of these chronic diseases. Each practice will receive expert coaching, peer support, and other hands-on training to identify a gap in care and then design and implement a quality improvement project to close it. 

Funded by the Mother Cabrini Health Foundation, the initiative will include up to five primary care practices. 

“Chronic conditions place a considerable, and unevenly distributed, burden on New Yorkers,” said Alice Ehrlich, director of UHF’s Quality Institute, in a statement. “By pairing proven quality improvement tools with the primary care setting, this project offers a powerful way to enhance care and address these disparities where most chronic conditions are diagnosed and managed." 

Practices will focus on chronic conditions of the highest priority to them and will measure and track their progress throughout their quality improvement projects. 

Patient voices will play a central role in both the learning collaborative curriculum and each participant’s intervention. When designing their quality improvement projects, primary care practices will be required to seek out patient perspectives through patient councils, surveys, or focus groups. This will ensure patient voices are not only central to the project, but that patients are seen as part of the practice’s project team. 

UHF will conduct interviews in multiple languages, to gather insights from New Yorkers living with chronic conditions who represent historically underserved groups. The research, which will explore prohibitive factors in accessing quality care, will be shared with the learning collaborative participants, and inform the curriculum—enabling UHF to curate speakers and topics most relevant to the New York City population.  

The new learning collaborative stems from UHF’s previous work in health equity and practice transformation.  

UHF has also seen success with the learning collaborative model, such as its work on reducing medication overload among nursing home residents. Each year of the medication overload work successfully reduced the average number of medications taken by participating nursing home residents. 

At the end of the initiative, UHF plans to publish a report with its wider network with hopes that lessons learned during the collaborative can inspire and inform others to improve equity in primary care.