Table 2.

Primary linkage interventions: systematic sharing of information

NORC-SSP site	Target condition	Description of systematic sharing of information
Mid-Manhattan	Transition from ED to community	• Daily email list of ED discharges within the NORC-SSP catchment area • Electronic medication record housed by and updates by local pharmacies
Lower Manhattan	Diabetes	• Shared Electronic Patient Database with diagnostic, treatment and appointment information
Queens	Falls	• Consultation letter from NORC-SSP to PCPs with results from the Hartford Falls Risk Assessment Protocol and recommendations for treatment and/or referral
Brooklyn	Depression	• Shared Client Passport with results from the Hamilton Depression Screening Protocol and notes on all medical and social work visits