The Visiting Doctors program was founded as an outgrowth of a conversation among three residents who were feeling frustrated at how the long hours and exhausting work of residency were taking away their humanity. They began developing ideas to combat the problem. One of their suggestions was a home visit program that would facilitate their going out into the community and seeing how their patients live. They contacted the Department of Community and Preventive Medicine and from there were put in contact with the Little Sisters of the Assumption. From this conversation a program that provides primary care services to homebound persons in Manhattan has grown.

Geriatric medical care and palliative care are provided to patients who can no longer get out to see their doctor or for whom going to a doctor would be an undue burden. From its inception the program has worked very closely with the Little Sisters of the Assumption Family Health Service—a nonprofit community-based organization that works with the people of East Harlem —to address the physical, emotional, educational, and spiritual dimensions of family health. While the relationship with the Little Sisters remains extremely strong, the program has expanded so that it now works with nursing services throughout New York City.

The majority of patients reside in East and West Harlem as well as the Upper East and West Sides of Manhattan. Patients are seen without regard for their ability to pay—78 percent have Medicare and 48 percent have Medicaid. The average patient age is 83. Thirty-six percent of patients are Latino, 31 percent African American, and 25 percent are white.

Four physicians, two nurse practitioners, and several community groups are involved in the program. Additionally all second-year residents spend one month going on home visits. The choice of second year for this rotation was to ensure that residents had sufficient experience before going on home visits, but were given as an anecdote to the cynicism that often effects residents.

The Visiting Doctors program has been inundated with referrals since starting service, indicating a great need for the program. The program has cared for more than 400 patients since inception and has an active census of 280 patients. Preliminary analyses show that many of the patients had little or no care in the year leading up to their referral to the program. After entrance to the program, less than 2 percent of patients have been lost to follow-up.

In 1991 the Department of Neurology began sponsoring programs to educate seniors about risk in the context of an NIH-funded Minorities Risk Factors and Stroke Study at Mount Sinai. The study is investigating the risk factors that lead to increased risk for stroke in African Americans and Hispanics. Most current knowledge about strokes comes from predominately white communities. Since half of Mount Sinai's stroke patients are African American or Latino, this research is directly applicable to the local community.

When TPA was approved for treatment of acute stroke in 1995, it became imperative to educate people on the importance of getting to the hospital as soon as possible. Doctors in the Department of Neurology conducted a second round of educational discussions in senior centers they had visited in 1991. They then requested formal funding from Mount Sinai's Auxillary Board to do larger scale programs and develop materials.

Mini-courses tailored to the audience are conducted in English and Spanish at more than 20 sites throughout the community. Stroke screening and blood pressure tests are often conducted at the site. Participants are given refrigerator magnets and posters describing stroke symptoms, prevention strategies and appropriate action to take and certificates indicating they have completed a stroke mini-course.

In addition to the initial sites, COSTEP conducts courses on an ad hoc basis whenever the opportunity arises. COSTEP educators have also participated in health fairs and traveled around East Harlem in a mobile laboratory, in conjunction with the Veterans Association, doing presentations and blood pressure screenings. They also conducted a "meeting without walls" for homebound people via conference call. Expansion is planned to educate caregivers of people who may be at risk for stroke, as well as stroke survivors.

In 1997 and 1998 COSTEP reached 1,000 neighborhood adults. Participants in the educational program are consistently enthusiastic and eager to learn more. At some of the programs, the participants have been asked to fill out questionnaires before the presentation and six weeks afterwards. Responses have clearly demonstrated a significant increase in ability to identify symptoms and name stroke risk factors and prevention strategies after participation.

In the 1970s, when the scandalous conditions at the Willowbrook Home were disclosed, profoundly mentally retarded and developmentally disabled children who had been residents of this large facility were dispersed to group homes around New York. As this population has aged, the State has sought more effective ways to provide medical services to these smaller homes. The Gouverneur Parents Association and the Metro New York Developmental Disabilities Services Office (OMRDD) began to seek a partner to help remedy the situation. Mount Sinai was approached to provide these services and a formal partnership was formed in 1997.

This pilot project is the only systematic program of care in the State to insure that profoundly disabled individuals have access to health care equal to that of anyone else in society. Prior to the program's establishment, many of these individuals did not receive annual physicals and acute problems were cared for by whatever provider could be found at the time or in emergency rooms ill-equipped to deal with this population.

Individuals from nine group homes are assigned to one of the primary care physicians from Mount Sinai's Internal Medicine Associates. They receive an annual physical and specialty care as needed. Mount Sinai has devised numerous methods to accommodate the unique challenges posed by this population. Emergency room staff and specialists work closely with primary care providers, social workers and other staff to ensure all necessary care is provided with consideration for the needs of the patient. Representatives from the Gouverneur Parents Association, the State and Mount Sinai meet on a monthly basis to evaluate needs and determine new directions for the program.

This program presents a unique teaching opportunity, not available in most medical schools. The residents learn how to be effective care providers to this population and have the opportunity to see them as individuals. It is hoped that this will encourage them to continue to seek ways of ensuring that profoundly disabled individuals are mainstreamed into regular primary group practice.

Mount Sinai has worked with its partners in this endeavor to enrich the lives of this population in other ways. Each year a gospel concert hosted by Mount Sinai is attended by hundreds of mentally retarded and disabled individuals and their families. Educational services for the families are also provided by Mount Sinai.

Mount Sinai School of Medicine has been honored by both the Gouverneur Parents Association and the State of New York for its service to this population. Mount Sinai faculty are working with the State not only to continuously evolve this Program to provide the best possible care, but also to discuss replicating it at other sites throughout New York State.

The Alzheimer's Disease Assistance Center began as a way to reach out to patients at risk of not receiving proper care because of barriers, especially language. The Center conducts bilingual programs throughout New York City to provide education on Alzheimer's disease and inform patients and caregivers of available medical services. The New York State Department of Health funds the Center.

A social worker from the Center conducts bilingual educational programs throughout the City, with a special focus on the predominantly Spanish-speaking community of East Harlem. Working on the premise that the only way to effectively reach out to people is to go to them, the program works closely with community centers, community boards, clergy and other community leaders to conduct lectures at community centers, health fairs and anywhere else the target audience can be reached.

Lectures focus on symptoms of dementia and methods for coping with the illness. The social worker explains treatment options and informs participants of places they can go in the community to seek help and medical care, including the Geriatric Psychiatry Clinic at Mount Sinai. The aim is to ensure that this previously underserved population knows that there are places they can go for care. Without such educational opportunities in their language, many Spanish-speaking people were unaware of available services and relied on primary care providers who were often ill-equipped to deal with this disease.

Since the founding of the Center, the number of Spanish-speaking Alzheimer's patients in the Geriatric Psychiatry Clinic at Mount Sinai has increased more than five-fold. Thousands of people have attended lectures and the response has been overwhelmingly enthusiastic. Participants are appreciative of the opportunity to learn about memory disorders and to learn that when they come to the Clinic for care, there will be people who speak their language. The increase in Spanish-speaking patients in the Clinic has led to the hiring of additional bilingual staff.

The Alzheimer's Disease Respite and Counseling Program was developed after a weekend retreat that offered ten families of Alzheimer's patients respite and counseling while special activities were held for the patients. While many existing programs offered respite and counseling, the idea of offering a combination of activities for caregivers and patients was new. There was also a dearth of support for Spanish-speaking caregivers and patients. Originally funded as a short-term program by the Mount Sinai Auxiliary Board, the Program now receives funding from the New York Department of Health.

By combining respite, education and counseling services for caregivers with patient activities, the Program removes the burden from caregivers of finding a substitute to look after the patient in their absence. Additionally, having caregivers and patients attending together offers the chance for caregivers to learn effective methods for caring for the Alzheimer's patient from the program's occupational therapist, social worker and nurse practitioner.

All programs are run in English and Spanish. The sessions also offer more extensive education and counseling in Spanish than other New York agencies. Referrals for the original short-term program came mostly from the Geriatric Psychiatry Clinic. To expand the population reached, sessions are now held throughout the community in conjuncture with other agencies including Harlem Hospital, the Alzheimer's Association, Jewish Home and Hospital, Brookdale Day Programs, Council Senior Center and Lenox Hill Neighborhood House. Both paid care providers and family members attend the sessions.

Last year, more than 80 bilingual lectures were given to more than 5,000 neighborhood residents. Working with agencies around the City, the Program is training others to run similar sessions at their centers.