OneCity Health Awards Eight Community Partners with $5 Million in Innovation Funds

OneCity Health, the NYC Health + Hospitals Performing Provider System under New York State’s Delivery System Reform Incentive Payment (DSRIP) program, today 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.

“Congratulations to our partners for submitting creative ideas that cover a range of topics, from opioid dependency to improving connections to care. Their innovations will help improve the health of our patients,” said Israel Rocha, CEO, OneCity Health. “Each project represents two important aspects of the DSRIP program, innovation and community collaboration. These innovative solutions help to bridge the gap to a value-based payment environment, and the collaborations between our community partners demonstrate a holistic approach to creating an integrated delivery system. We look forward to helping to foster these programs over the next year and seeing their results.”

OneCity Health awarded funding to the following projects:

1) 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.

2) 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.

3) 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.

4) 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.

5) 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.

6) 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.

7) 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.

8) 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.

The $5M Innovation Fund was open to all OneCity Health partners, which include more than 160 community-based organizations, hospitals, physician practices, pharmacies, and behavioral health practitioners, among others. OneCity Health encouraged partners to collaborate and submit joint applications and ultimately received 41 applications from 55 partners.

Projects will start on July 1 and run for a year. Completed project evaluations will be due September 1, 2019.

The $5M fund was one of the largest allocations set aside by a Performing Provider System across the State to support more community collaborations, innovations, and best practices.