Table 6.

Increased shared care planning

Site	Evidence
Mid-Manhattan	• Providers reached out to the NORC-SSP to get information on shared patients or to find out how to enroll other patients into the Linkage project
Lower Manhattan	• Fifty-two collaborative assessments of diabetes status conducted for the target patients over the course of the year • Quarterly group visits at the primary care center drew approximately 5 NORC program clients each time • Fifty-six percent of residents report seeing the NORC-SSP and the primary care center staff work together to assist them in their diabetes treatment
Queens	• Providers responded to assessment findings and care plan recommendations that were sent by the NORC-SSP nurse or presented by the resident • Residents reported that physicians began asking them about mobility issues and falls
Brooklyn	• Twenty-four percent residents reported that their physicians either looked or wrote in the client passport