OneCity Health selected 11 projects from a list of 44 options offered by the state that align with the results of its Community Needs Assessments. Metrics gauging progress under each of the 11 projects will be tracked and submitted to the state in accordance with DSRIP program requirements. Each project is described in detail below.

It is important to understand that our overarching objective is to achieve system transformation by working collaboratively with our partners to create a delivery system that is truly patient-centered. In this sense, OneCity Health will train its focus on thoughtful and deliberate consideration of the patient’s journey along the continuum of care. By focusing on this journey, we have developed an approach to DSRIP project activation that groups projects which share common thematic elements. These groups and their corresponding activities are:

  • Strengthen Primary Care and Behavioral Health
    • Integration of primary care and behavioral health services
    • Evidence-based practices to improve cardiovascular disease management
    • Integration of palliative care into primary care setting
    • Enhancement of asthma self-management in pediatric patients
  • Enhance Outreach and Activation
    • Comprehensive program to actively engage patients in high-quality, patient-centered care, regardless of insurance status
  • Ensure Robust, Targeted Care Management
    • Global risk stratification
    • Episodic or longitudinal care management support that meets patient needs and promotes self-management
  • Support Seamless Care Transitions
    • Evidence-based care coordination and PCP linkage for patients presenting to the ED for non-urgent care
    • 30-day supported post-hospitalization transitional care services for patients at risk for readmission

Key to Success

OneCity Health is committed to culturally and linguistically competent care.

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Community Needs Assessment

To determine specific needs, OneCity Health completed four borough-based community needs assessments.

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Asthma home-based self-management program

Objective: To ensure implementation of asthma self-management skills including home environmental trigger reduction, self-monitoring, medication use, and medical follow-up to reduce avoidable ED and hospital care. Special focus on children where asthma is a major driver of avoidable hospital use. Click here for recent news on asthma home-based self-management
Application Details: PDF

Cardiovascular disease management

Objective: To support implementation of evidence-based strategies and best practices for disease management in medical practice for adults with cardiovascular conditions.
Application Details: PDF

Care transitions model

Objective: To provide a 30-day supported transition period after hospitalization to ensure discharge directions are understood and implemented by patients at high risk of readmission, particularly those with cardiac, renal, diabetes, respiratory and/or behavioral health disorders. Click here for recent news on Care Transitions
Application Details: PDF

Emergency Department (ED) care triage

Objective: To develop an evidence-based care coordination and transitional-care program that will assist patients presenting to the ED for non-urgent care to link with a PCP, support patient confidence in understanding and health condition self-management, improve provider communication, and provide supportive assistance. Click here for recent news on ED Care Triage
Application Details: PDF

Health Home at-risk intervention program

Objective: Proactive management of higher risk patients not currently eligible for Health Homes through access to high-quality primary care and support services. To expand access to community-based, primary-care services and to develop integrated care teams to meet the individual needs of higher-risk patients who do not qualify for care-management services from Health Homes. Click here for recent news on Health Home At-Risk
Application Details: PDF

HIV Care

Objective: Increase the percentage of HIV+ persons who are in care and increase the percentage of HIV+ persons who are virally suppressed by expanding testing and other services and increasing early access and retention in care.
Application Details: PDF

Mental health and substance abuse infrastructure

Objective: Support collaboration among leaders, professionals, and community members working in MEB health promotion, substance abuse, and other MEB disorders and chronic disease prevention, treatment and recovery. Strengthen infrastructure for MEB health promotion and MEB disorder prevention. Click here for recent news on Mental Health and Substance Abuse
Application Details: PDF

Palliative care

Objective: Identify appropriate primary care practices, preferably those already using the PCMH model, to integrate Palliative Care supports and services into their practice model. Click here for recent news on Palliative Care
Application Details: PDF

Patient activation activities
“Project 11”

Objective: To engage, educate, and integrate the uninsured and the non- and low-utilizing Medicaid populations into community-based care. This project aims to increase patient activation related to health care by pairing efforts with increased resources to help patients gain access to and use the benefits associated with OneCity Health projects, particularly primary and preventive services. Click here for recent news on Project 11
Application Details: PDF