Thread by @davechokshi

Personal news: after 6 unforgettable years, I am stepping down from my leadership role at @NYCHealthSystem. Mixed emotions to say the least! But most of all I feel grateful to have served the mission of this extraordinary organization.

Please indulge me as I recount some of our proudest accomplishments on behalf of patients. Far and away the most important one was forging this amazing team—

Our vision was to build a better health system, one with a more proactive approach to addressing avoidable human suffering. More on what that means here: hbr.org/2019/10/4-prin…

Our #populationhealth strategy flowed from that vision, organized around four pillars.

1/ Identifying and stratifying an attributed population
Our high-performing Medicare ACO showed how to improve quality while avoiding unnecessary hospitalizations, particularly for our sickest patients. Thanks @DrNickStine @DrRossWilson and many others. healthaffairs.org/action/showDoP…

We worked to scale that approach to our entire population of patients, and to other safety-net health systems. For instance, we built a model to proactively identify high-risk patients, and published it #openaccess. link.springer.com/article/10.100… @jziring

2/ Grounding in high-quality, community-based care
We endeavored to move the system's center of gravity into our primary care clinics and further into the communities we serve. healthaffairs.org/do/10.1377/hbl…

We launched @CommunityCareNY, led by @NJordanMartin, to deliver better care in patients' neighborhoods, and community health worker and home-based primary care programs, led by @j9knudsen. nychealthandhospitals.org/pressrelease/n…

3/ Meeting patients where they are
We sought to "move knowledge, not patients" through programs like @ProjectECHO & @myopennotes; since launching eConsult in 2016, H+H has scaled it systemwide, improving access to specialty care @HannahRoseBE @SingerJesse nychealthandhospitals.org/pressrelease/n…

We also worked to tear down siloes by linking physical health, behavioral health, and social needs. For example, collaborative care integrated mental health into primary care, with demonstrable improvement in outcomes. @imjessblack @SingerJesse catalyst.nejm.org/doi/full/10.10…

We chartered the system's first social determinants team and strategy, focusing on housing, food, income, and legal needs. Our longstanding medical-legal partnership with @nylag is a shining example of how social factors affect patients' health. medical-legalpartnership.org/mlp-resources/… #SDOH

4/ Using data to drive improvement
For us, analytics was a way of holding ourselves accountable. Beyond good intentions, did we actually improve our patients' lives? We sought to infuse that into our dashboards and our programs. @Remletweets

Our blood pressure and diabetes control rates reached new highs, saving lives and limbs, thanks to our dedicated clinicians and chronic disease coordinators, and led by @nichdavis.

This neat thread belies how much there was that didn't work, or at least not yet! One way we always tried to keep that at the forefront of our minds was through a focus on the 'patients we do not see' scientificamerican.com/article/the-pa…

Finally, #COVID19 tested us (and continues to) in a way no other crisis has. We have all borne witness to too much suffering, by our patients, neighbors, colleagues. Proud at the same time to have been a part of @NYCHealthSystem's response. knowledge.wharton.upenn.edu/article/new-yo…

At historic institutions like @NYCHealthSystem, we are all just temporary stewards of a mission far greater than ourselves. Grateful to have served with so many inspiring colleagues, and looking forward to watching them take the work to even greater heights.