Partnerships Projects

Partnership with New York Presbyterian Hospital (NYP)

In 2005, New York Presbyterian Hospital (NYP) and community leaders initiated the Washington Heights-Inwood Network (WIN) for Asthma Program– a community health worker (CHW)-led initiative to address local health disparities and to improve outcomes for children with poorly controlled asthma.



As a result of demonstrated impact, in 2015 the Northern Manhattan Perinatal Partnership (NMPP) and the Center for Community Health Navigation (CCHN) at New York Presbyterian Hospital, co-developed and implemented a DSRIP (SKATE) funded Community Health Worker (CHW) led program to support children with special health care needs with CHWs employed by NMPP. In July 2017, the pediatric programs were combined to form the Pediatric Community Health Worker Program.

Oberkotter logo

In 2018 NMPP and CCHN at NYP co-developed a CHW-led program to support children with hearing loss and their families with CHWs employed by NMPP.

The goals of the Pediatric CHW Program are to help patients and their caregivers address the social needs that interfere with health management and well-being and to support coordination of care.

Role of the Community Health Worker (CHW) with SKATE & Oberkotter

  • Conduct home visits

  • Provide appointment accompaniment (medical, social services, school)

  • Deliver and reinforce education around 3 key messages:

  • Know your child’s condition(s)

  • Know how to access health care for your child

  • Keep your child’s condition(s) under control

  • Support participant’s goals around their child’s care, including:

  • Medication management

  • Transitioning from pediatric to adult medicine

  • Organizing to best coordinate care and manage appointments

  • Linkages to address social challenges, including: housing, immigration, employment, etc.

Partnerships for Early Childhood Development (PECD)

  • NMPP partners with the PECD at Colombia University Medical Center (CUMC) on a project that involves screening for psychosocial determinants of health during well-child care visits, in order to provide comprehensive upstream care to the families, and maximize the child's potential, well-being, and school readiness.

  • The project focuses on utilizing a set of surveys (including the SWYC: survey of the well-being of young children) during well-child visits, to stratify patients into three levels of risk and connect them with resources accordingly.

  • The CHW (employed by NMPP) is an integrated member of the PECD team and works in collaboration with representatives from New York Presbyterian Hospital (Charles Rangel clinic) and NMPP through the Healthy Start program.

Role of the Community Health Worker (CHW) with PECD

  • Support children and families who are in Level II of risk stratification.

  • Outreach & provide peer support to families.

  • Engage with families regarding child development/behavior.

  • Assist with the completion of the ages and stages questionnaire (ASQ) when appropriate.

  • Connect parents to parenting resources and services offered by community partners. 

  • Conducting a home visit when needed.


  • For children with poorly controlled asthma enrolled in the program, to date, hospitalizations rates have decreased by 76%.

  • Emergency department (ED) visits decreased by 68%.

  • 97% of caregivers reported feeling able to manage their child’s asthma.

  • 83 of the caregivers with unmet social needs were successfully connected to social service resources that address needs related to housing, food insecurity, and insurance.

  • Nearly 65% of the 157 caregivers who completed the program reported decreased levels of distress upon discharge.

Family Peace Center

  • In 2018 NMPP partnered with the Family Peace Center to provide trauma screening, assessment and therapy services for women with children 0-5 yrs. old.

Partnership with the University of California, Berkeley School of Public Health.

Best Babies

Best Babies Zone, Harlem 

In 2017 NMPP partnered with UC Berkley School of Public Health to create Best Babies Zone, Harlem (BBZ Harlem). “Best Babies Zone, Harlem” is the first Best Babies Zone in the whole Northeast for this national initiative. The BBZ approach is a place-based, multi-sector, community driven effort to reducing racial inequities in birth and life outcomes, by mobilizing community residents and organizational partners to address the social determinants of health. 

BBZ Harlem is comprised of specific areas in the 10027 zip code, particularly the Manhattanville and Grant Houses and the surrounding area. 

Mission: To give every baby born in a Best Babies Zone the best chance in life. 

Partnership with Morris Heights

NMPP works collaboratively with Morris Heights Health Center to provide a navigator once per week to enroll eligible community residents into health insurance and SNAP.