Innovation Award Program

On June 12, 2018, OneCity Health announced the eight community partners that will receive funding from its $5 million Innovation Fund to implement programs targeting DSRIP priorities and the public health system transformation goals, including reducing avoidable hospitalizations, improving community health outcomes, and addressing social determinants of health, such as food security and health literacy.

Click here to read the announcement press release.

OneCity Health awarded funding to the following projects:

Lead Organization: Acacia Network

Joint Applicants: St. Ann’s Corner of Harm Reduction, Seedco
Project Title: Bridging Access to Benefits and Care
Budget: $699,450
About the Project: Focused on addressing the social determinants of health for the disenfranchised opioid-dependent population in the Bronx, Acacia Network and its joint applicants will conduct outreach to this population through peer specialists and enroll them in public benefits.

Click here to read more about this project.

Lead Organization: The Fortune Society, Inc.

Joint Applicants: NYC Health + Hospitals/Correctional Health Services
Project Title: Connections to Care (C2C) Program
Budget: $487,000
About the Project: The Fortune Society and NYC Health + Hospitals/Correctional Health Services will implement the Connections to Care Program to provide individuals on Rikers Island who will soon be released with physical, behavioral, and social health assessments. Upon release, participants will be offered transportation and then connected to a health care provider to receive essential health care, including medication-assisted treatment for those with opioid use disorder who received such treatment at Rikers.

Click here to read more about this project.

Lead Organization: Korean Community Services of Metropolitan NY

Joint Applicants: Mexican Coalition, Health People, New York City Department of Health & Mental Hygiene
Project Title: Strengthening Community-Clinical Linkages to Address Social Determinants of Health in Connection with Chronic Disease Self-Management
Budget: $750,000
About the Project: Through this project, Korean Community Services of Metropolitan NY and its joint applicants will enhance the Stanford Diabetes Self-Management Programming model by incorporating linkages to insurance, primary care, and resources to address social determinants of health.

Click here to read more about this project.

Lead Organization: MJHS Health System/MJHS Institute for Innovation in Palliative Care

Joint Applicants: NYC Health + Hospitals/Gouverneur and NYC Health + Hospitals/Kings County
Project Title: Achieving Best Practices in Advance Care Planning and Hospice Referral: A Novel Nurse-Mediated Collaborative Practice Approach for Primary Care
Budget: $600,000
About the Project: MJHS Health System/MJHS Institute for Innovation in Palliative Care and its joint applicants will improve both advance care planning and appropriate access to hospice care for seriously ill patients living in the community. A nurse, placed in the primary care setting, will serve as a hospice and palliative care resource, creating new processes for patient screening, facilitating culturally sensitive discussions with patients and families, identifying hospice-eligible patients, and coordinating care to guide hospice enrollment.

Click here to read more about this project.

Lead Organization: NYC Health + Hospitals/Kings County

Joint Applicants: University Hospital of Brooklyn, CABS Home Health Attendants Services, Inc.
Project Title: Developing an Asthma Smartphone Application Targeting Children and Families with Low Health Literacy: The “AsthMe Ask Me!” Program
Budget: $279,500
About the Project: NYC Health + Hospitals/Kings County and its joint applicants will develop an asthma smartphone application targeted to patients and caregivers with low health literacy to increase understanding of pediatric asthma and its management. The application called “AsthMe” will consist of a variety of images and videos.

Click here to read more about this project.

Lead Organization: Public Health Solutions

Joint Applicants: Bronxworks, The Food Bank of New York City, God’s Love We Deliver, Healthfirst, NYC Health + Hospitals/Jacobi and /Lincoln
Project Title: Addressing Food Insecurity through a Food and Nutrition Services Bundle in the Bronx
Budget: $704,050
About the Project: Public Health Solutions and its joint applicants will develop the Food and Nutrition Services Bundle, a tool and gateway to comprehensive, community-based food and nutrition services in the Bronx. The Food and Nutrition Services Bundle will include a tool focused on coordinated intake and risk assessments for food and nutrition services, plus a referral platform to coordinate warm handoffs.

Click here to read more about this project.

Lead Organization:
RiseBoro Community Partnership

Joint Applicants: LISC NYC, NYC Health + Hospitals/Woodhull, New York Academy of Medicine
Project Title: Wellness Rising
Budget: $780,000
About the Project: RiseBoro Community Partnership and its joint applicants will identify clients of all ages with hypertension and provide individual care through community health workers, as well as health education classes, home visits, medication review, BP/glucose weight monitoring, linkages to social and support services and primary care, cooking workshops, and nutritional information. The program will also include a fresh-foods-by-prescription program.

Click here to read more about this project.

Lead Organization: South Asian Council for Social Services

Joint Applicants: Voces Latinas, Polonians Organized to Minister Our Community, The Young Women’s Christian Association of Queens Inc.
Project Title: Culturally Responsive Collaborative of Queens
Budget: $700,000
About the Project: South Asian Council for Social Services and its joint applicants will provide culturally competent health literacy education through workshops, presentations, and educational flyers to immigrants, focusing on South, Southeast, and East Asians, Hispanic/Latinos, and Eastern Europeans. A Patient Navigator will help clients acquire fundamental skills to navigate the health care system, connect them to health insurance or primary medical care, and promote self-efficacy to help them manage their health conditions towards optimal health.

Click here to read more about this project.

Program Background

During the first half of the New York State DSRIP program, OneCity Health worked with partners to develop an Integrated Delivery System and implement targeted programs to meet DSRIP goals. As part of the evolution towards a value-based payment environment, OneCity Health launched the $5 million Innovation Fund program on January 29, 2018. The aim of the program is to support Performing Provider System (PPS) partners in designing and implementing innovative programs to improve the health of the patients and clients we serve and reduce avoidable use of the health care system.

And in the spirit of the DSRIP program – OneCity health strongly encouraged collaboration among partners (click for partner contact list) and to focus on the social determinants of health. All partners with a signed Master Services Agreement (MSA) as of January 1, 2018 were eligible to submit an application. The deadline was March 2, 2018.

OneCity Health expected to fund up to 10 projects in total; awards were expected to be in the range of $250,000 – $1,000,000 per selected application.

Program Materials

Program Application

Click here to download the program application (no longer eligible for submission). The application included the selection criteria, more details on the program and process.


Priority Outcome Measures

Applicants for the OneCity Health Innovation Fund were asked to describe how their proposal impacts DSRIP Outcome Measures. To help, click here for OneCity Health’s priority Outcome Measures.