NYP/ACN Resources

Who this message is for: All pediatric and adolescent healthcare providers.

What is happening: New ambulatory referral process for the Compass Program, a dedicated gender-affirming care clinic for patients up to age 19 years.

How this will affect you: Effective Thursday, February 9, 2023, a new ambulatory referral order and process will be live in EPIC to connect patients to the Compass Programs either at Columbia University Medical Center or Weill Cornell Medical Center.

Description of The Compass Program:

Compass is a comprehensive and interdisciplinary gender-affirming care program for transgender and gender-diverse individuals and their caregivers to be seen in a safe, welcoming, and nonjudgmental space.

Services can include:

• Comprehensive and individualized needs assessment

• Family support

• Collaboration with schools and other organizations

• Sexual and reproductive health counseling

• Gender-affirming medicines

How to refer patients to Compass:

Search for “AMB Referral to Compass Program” as an order. Providers can also search for any of the following terms:

• “Compass

• “Transgender”

• “Gender”

Who to contact with Questions/Feedback:

Questions about the program: Compass Program: 646-369-6905 | obk7001@nyp.org

Questions about Referral Order:  Submit a message to Epic Support directly by clicking on the “Epic Help” button within Epic itself, email epictogethersupport@nyp.org, or call your institutional Service Desk:

• NYP: 4-HELP or 212-746-4357 | servicedesk@nyp.org

• CUIMC: 5-HELP or 212-305-4357 | 5help@cumc.columbia.edu

• WCM: 212-746-4878 | support@med.cornell.edu

• Behavioral Crisis Program:

At the Farrell Clinic this can be shown through our MH Social Worker’s pool. Every time a patient scores on the PHQ-9 our safety in-basket catches these responses and one of our MH social workers assesses the patient. Next steps can look like, safety planning, CSSR assessments, MH referrals, or enrolling in short time counseling with out MH SW 

• Center for Community Health & Education (CCHE): 

CCHE’s programs deliver clinical services at the Family Planning Practice at 21 Audubon Avenue and the 7 School Based Health Centers (SBHC) serving 23 public schools.    

Patients needing contraception, general gyn care, medication abortion and STI services can be referred to the Family Planning Practice by Epic referral, by phone or by messaging the practice supervisors.  You could also connect with the social worker Jorge Gonzelez, jog9014@nyp.org 

By NYS DOH regulations, the SBHCs can only serve students enrolled in their campus schools. If you know that a patient was enrolled in one of the schools, you could connect with the social worker or psychologist at the school.  

The teen Peer Educators are students from these 23 schools who have receive intensive training to provide education to their peers.

Referral Workflow Notes for CCHE:

Family Planning Practice by Epic referral, by phone or by messaging the practice supervisors.  You could also connect with the social worker Jorge Gonzelez, jog9014@nyp.org 

List of School Based Health Centers (SBHC) and the public schools they provide to contact schools and connect with Social workers or psych 

• Community and Faith Based Partnership Program:

This is called Building Bridges Knowledge and Health (BBKH). This program works within the churches and community organizations within Harlem, Northern Manhattan, and the Bronx. They do not work with patients directly, but they work with FBO’s and Churches, meeting the last Tuesday of every month. This aims to connect community members and their churches to healthcare resources like primary care and education to improve the health of our neighborhoods. 

Point of Contact for BBKH: Any organization or staff member looking to learn more can contact Maximiliano Maldonado Orozco, mam9588@nyp.org , to gain more information. This is NOT for patients directly. 

• Health for Life:

Health 4 Life (H4L) is a family-centered lifestyle intervention program for overweight children and adolescents at New York-Presbyterian. It was established in 2006 in response to the nationwide obesity crisis. 

Participants in H4L must be 4-18 years old and have a BMI equal to or greater than the 85th percentile for age and gender. Pediatricians in the NYP Ambulatory Care Network can refer their patients to the program at both the Cornell and Columbia campuses. Participants in H4L come from all five boroughs of New York City but must receive their primary care at one of the NYP-ACN pediatric practices. 

Mission 

Our mission is to provide a safe and supportive environment for 4-18 year-olds and their families who are interested in improved health through healthier diets and increased physical activity. 

The Program 

Participants begin with a clinical visit for a medical/nutrition/psychosocial intake and for a physical fitness assessment. In this setting, individuals meet with the interdisciplinary team of a pediatrician, registered dietitian, social worker, and exercise physiologist. Dietary and exercise goals are discussed and tailored to meet each family’s needs. Clinical appointments are provided both in person and through video visits. 

Most participants 7 years and older are given an invitation to join weekly exercise classes led by the team exercise physiologist. During the physical activity portion, the clinical exercise physiologist works on improving participants' aerobic activity, muscle strength and bone strength. In this fun, supportive environment the exercise specialist promotes teamwork, builds confidence, and creates positive attitudes and beliefs towards exercise and movement. 

H4L parents and caregivers are offered the opportunity to join nutrition education support groups led by staff registered dietitians. During this 10-week program, parents meet, share ideas, and receive support from other parents, and delve deeper into nutrition with the registered dietitian. 

The Heath4Life program works to empower participants to make healthier lifestyle choices for themselves and the whole family. 

Referral Workflow: Providers must place Referral through EPIC referral process  

• Healthy City Kids (HKC):

This is a healthy lifestyle and obesity prevention program for families of pre-school aged children is only for those who can enroll in HeadStart. If Families are at Lenox Hill Neighborhood House Head Start, they can inquire at school.  

The Healthy City Kids curriculum, which was developed by a team of pediatricians and a pediatric nutritionist at NYP-WCM with parent input, consists of six weekly interactive nutrition education sessions taught to caregivers of the enrolled pre-school children. The six-week program is offered throughout the academic year in both English and Spanish. 

Weekly sessions are taught by pediatricians, pediatric medical residents, and a registered dietitian. Caregivers learn about healthy eating practices and fun, age-appropriate physical activities for their young children. Each class includes nutrition learning sessions, take-home activities for the families, and a review of the previous week's family activities. The program also utilizes an evidence-based physical activity program for preschoolers called "Animal Trackers," which gives families age-appropriate physical activities to use at home. 

Ask about this program at:  

Lenox hill neighborhood house headquarters 

331 East 70th Street
New York, NY 10021
212-744-5022 

or by visiting their website: Healthy Foods + Wellness Lenox Hill Neighborhood House 

• Health Homes:

This is no longer a program as of 3/31/2024, however, Social Work and Providers can make external referrals. Below you will find some Health Home agencies, and points of contact.  

Health Home Serving Adults/Children: 

Primary Contact – Nathan Ito-Prine, (917)-566-9314, nathan.ito-prine@ccmphealthhome.org 

Alternate Contact: Ana Tabachneck, (646)-799-0781, ana.tabachneck @ccmphealthhome.org  

Referral Contact – Robert Ward, (646)-799-1892, robert.ward@ccmphealthhome.org 

Member Referral Contact (Self-referral): 888-682-1377 

Website: Health Home Care Management New York | Community Care Management (ccmphealthhome.org)  

Counties Serving Adults: 

Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Staten Island 

Counties Serving Children: 

Bronx, Kings (Brooklyn), New York (Manhattan), Queens 

• Family Peace Trauma Center:

The Family PEACE Trauma Treatment Center offers child-parent psychotherapy (CPP) to children ages 0 to 5 and their caregivers, who have experienced or witnessed any form of trauma. We also offer services to any sibling up to the age of 12. We are open Monday to Friday from 9am - 5pm. I have attached our referral form and our brochure for you to review. 

Once we receive and review the referral, we will contact the family within 5 business days to schedule an intake assessment. After the intake, we discuss the family as a team and decide whether we are the best fit for the family. If we are a good fit, we place families on our waiting list, and if we are not a good fit, we work with the families to identify a different organization or program to refer them to.  

Our waiting list is about 1 month long right now. While on the waiting list, families are contacted monthly for check-ins. Families also have access to groups and other services like yoga, art, legal, spiritual counseling, and some case management while on the waiting list. If families experience acute situations, we can move them up on the waiting list, pending clinician availability

(Brochure and referral form are the documents attached below)

NYP Long Covid Program 

NYC Health and Hospitals After Care Program