New York Children’s Health Project, a program of Montefiore Medical Center, has served New York’s most marginalized children and families since 1987.

Located in the poorest congressional district in the country, CPP is a cluster of three federally qualified health centers that serve children and families living in the South Bronx, along with a fleet of mobile medical clinics that serve families living in homeless shelters throughout four boroughs of NYC.

CPP’s medical home model of care is designed to address the complex health and psychosocial needs of vulnerable families, offering them access to primary care with co-located and integrated mental health, case management and crisis intervention, women’s health and prenatal care, chronic disease management, substance abuse prevention, nutrition services and emergency food assistance, specialty care referral management and transportation assistance.

Services

– Comprehensive primary care across the lifespan
– Care for chronic diseases like asthma, diabetes, cardiovascular disease, etc.
– Women’s health care, including prenatal care
– Mental health counseling, assessment, crisis interventions, and referrals
– Substance abuse prevention, treatment, and referrals
– Emergency food assistance
– Specialty care referral managements & transportation assistance
– Access 24/7 to medical providers on-call
– Services are provided regardless of the ability to pay

Linkages

NYCHP’s Referral Management initiative improves access to subspecialty care and uses a team of family health workers (referral managers) and an active transport service to facilitate this process.

NYCHP referrals provide linkages with Montefiore Medical Center, many other hospitals for emergency and other specialized services, and social services agencies, including early intervention programs, domestic violence services, drug treatment programs, legal services, WIC and food stamp programs, emergency food, and public assistance and Medicaid offices across the city.

Statistics

Estimated homeless population: 133,000 in 2018

Patients served: 2,845 in 2018