Sharing the Success of NOURISH

This year’s conference theme is “Realizing the Benefits of Dissemination & Implementation Science.” The 2025 program will explore success stories, methodological advancements, challenges, and opportunities to realize the benefits of our science across health care, community, and public health systems.

Dr. Ortiz will be sharing some amazing updates from our NOURISH partnership! Specifically, she will be presenting on how our cross-organizational team has adopted and enhanced the Clinic-to-Community-Linkage (CCL) Model to identify implementation barriers and develop strategies to increase CCL referrals.

Our partnership sought to address inefficiencies in our referral pathway and quantify referrals, enrollments (meals delivered), and dis-enrollments, all while capturing provider and client feedback.

The NYU NOURISH team found two barriers:

1. Inefficiency for clinicians
2. Delays in submitting timely referrals with the required clinician approval

Through this work and due to an incredibly generous gift by the Batty Family Foundation, in partnership with our team, we launched two solutions:

1. A Smartset on the electronic health record that would allow the information to be transferred smoothly
2. Support from a dedicated community health worker

We are happy to report that since we began our work, referrals have increased from 13 at the start of this partnership to 208, with 10+ referrals a month.

Our shared clients and patients represented diverse communities, spoke seven languages, and included a majority (83%) who have public insurance.

We know that bidirectional community-academic partnerships are essential to meeting the needs of New Yorkers who are most vulnerable, and our shared work highlights that not only can we increase referrals within a critical time window, but that these partnerships can also lead to enhanced services and positive effects.

We are so grateful and excited to share this momentous announcement with our co-authors: Shilpi Mehta-Lee, MD, Stephanie Quintero Chacon, Eric Rochman, MPH, Priscilla Upshaw, MPH, Jessica Gonzalez, Joanna Madigan, MPH, Kathleen Hopkins, Meleen Chuang, MD, Rebecca Gallager, Brita Roy, MD, MPH, Antoinette Schoenthaler, EdD, Gbenga Ogedegbe, MD, MPH, Christina Kim, PhD, and Rachel Gross, MD.

You can read more about our NOURISH partnership here.

What: 18th Annual Conference on the Science of Dissemination and Implementation in Health
Where: Gaylord National | National Harbor, MD
When: December 14-17, 2025
Event Website