Linking Patients to Primary Care and Social Services Through Project 11

The initial phase of Project 11 focused on administering the Patient Activation Measure® (PAM®) survey to uninsured individuals. However, our transformation goals extend far beyond surveys; it is about effective outreach, linkage to primary care and social services, and training our partner staff to engage clients and patients in a culturally humble way so that they actively participate in managing their health conditions.

Marjorie Momplaisir-Ellis, Senior Director of Engagement and Collaboration and Annika Ginsberg, Brooklyn Hub Director and Project 11 Project Manager, both of OneCity Health, discussed our work at the November 16, 2016 “Community Connections” briefing series hosted by the Greater New York Hospital Association. They presented on how the partnerships between community-based organizations (CBOs) and NYC Health + Hospitals as part of the Delivery System Reform Incentive Payment (DSRIP) program are essential to meeting this goal and the creation of an integrated delivery system that includes the uninsured.

The PAM® survey is a valuable tool to begin conversations with patients about the importance of health insurance and the use of preventative services. However, how do we help patients to better engage with their health when, for many community members, their main use of the system is reactionary, such as a visit to the Emergency Department?

OneCity Health contracted with 17 NYC Health + Hospitals facilities implementing Project 11 and 35 community partners across four boroughs to administer the PAM® and connect individuals to insurance and primary care. From April, 2016 through September, 2016, across the Bronx, Brooklyn, Queens and Manhattan, our community-based partners administered 4,055 PAM® surveys, connected 1,246 people to primary care and 1,828 individuals to insurance.

As the OneCity Health team members discussed, partnerships with CBOs enable these connections by bringing trust and local knowledge to the community, proactively engaging with people about their health. Moreover, we’ve integrated social service providers, who may have less experience in this area, but can impact health outcomes through their work to tackle social determinants of health, like housing and food security.

Appointments for preventative care and insurance are just the beginning of the development of a truly integrated delivery system. In future years, OneCity Health will continue to work with community partners to move beyond counting the number of appointments to capturing patient engagement in a more meaningful way, such as tracking the proportion of appointments kept and insurance applications completed. Additionally, a care management screening tool will be developed so that both health care and social service providers can screen individuals for social service needs.