Partnership in Care Asthma Webinar Now Available to View

In this presentation, we discussed how a partnership between the primary care team and community health worker is essential for effective asthma management for children with asthma. Moreover, we highlighted how asthma self-management education improves patient outcomes, as community health workers utilize a written Asthma Action Plan tailored to the needs and literacy levels of the patient to reinforce patient education provided by the clinical team.

Click here to view the slides or view the full webinar below.

OneCity Health Launches City-wide Program to Better Treat Kids with Asthma and Reduce Avoidable Hospitalizations

NYC Health + Hospitals/OneCity Health today announced the launch of a population health and care management program designed to reduce hospitalizations among New York City children who suffer from frequent or severe asthma attacks. The home-based environmental management program assigns community health workers to visit homes to identify asthma triggers, reinforce strategies to help patients and their families maintain control over asthma, and supply free pillow cases, special cleaning supplies, and professional pest control services as needed.

OneCity Health—a subsidiary of NYC Health + Hospitals focused on population health, care management, and implementation of the State’s Delivery System Reform Incentive Payment (DSRIP) program—is aligning the public health system and its community partners, having already completed its first 500 home assessments, with plans to expand the program to hundreds more children and families this year.

“Asthma is the third-leading cause of hospitalization among children under the age of 15 in the United States, and oftentimes it’s because families may not understand how to reduce triggers or may struggle to address underlying determinants of health, such as substandard housing conditions,” said Dr. Luis Rodriguez, Chief of Pediatrics at NYC Health + Hospitals/Woodhull. “Controlling asthma requires getting to the root of the issue, including triggers in the home, and ensuring patients have access to the proper medications.”

“Through these transformation initiatives, which were enacted through the DSRIP program, we are connecting primary care physicians with community health workers and home remediation services, helping professionals across these organizations work together to care for patients with asthma,” said Andrew Kolbasovsky, Chief Program Officer, OneCity Health. “Our goal is to improve the quality of life for affected children, making sure they don’t miss school or avoid physical activity due to their asthma. That begins with creating a care plan focused on prevention, making sure patients don’t need to come to the emergency department or spend the night at the hospital because of asthma attacks.”

“Community partners and community health workers are essential to engaging patients,” said Janise Germosen, LMSW, Community Health Worker Supervisor and Social Work Care Manager at Asian Community Care Management, a OneCity Heath community partner. “We know our communities well and have done outreach before, so patients are more comfortable allowing us into their homes, which is an important element of support in the program.”

The home-based environmental management program for children with asthma is run by the following OneCity Health partners:

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The program’s initial focus is on pediatric patients with poorly controlled asthma, defined as overuse of “rescue” medications, use of systemic corticosteroids two or more times in the last six months, two or more asthma-related emergency department visits in six months, or hospitalization related to asthma in the past year. Program data will be tracked, including the impact on the proper use of medication and reduction in asthma-related hospitalizations, both DSRIP priorities.

After identifying a patient with frequent or severe asthma attacks, the primary care team develops an Asthma Action Plan and refers the patient to a community health worker. The community health worker meets with the patient and reinforces recommendations from the clinical team, including self-monitoring strategies and instructions on the correct use of medications. In addition, the community health worker conducts a home visit to evaluate the environment for asthma triggers, such as rodents, pests, mold, and dust. Based on the assessment, the community health worker can provide pillow cases and cleaning supplies, instruct families in home-cleaning strategies, and engage with the New York City Department of Health & Mental Hygiene—OneCity Health’s partner providing professional cleaning and pest management—at no cost to the patient.

Community health workers ensure that patients and their families are adhering to the Asthma Action Plan on an ongoing basis, through both home visits and phone calls. The community health workers also communicate with each patient’s clinical care team, using care management software to document interventions and receive alerts when patients are in the hospital.

New Workgroup and Technical Assistance Participants Reflect Diversity, Expertise of our Partners

Thank you to all of our partners who expressed interest in our recent Project Participation Opportunity (PPO) for the Strategic Advisory Workgroup. Although participation is limited to ten organizations, we received 17 applications. In order to ensure that this workgroup reflects the diversity of our community partners and a variety of expertise that are key for the work ahead, partners were selected with experience in areas such as contracting with managed care organizations, training and implementing Community Health Worker programs, designated Health and Recovery Plan (HARP), Intellectual and Developmental Disabilities (IDD), increasing health care access, and support for senior citizens.

The following organizations have been asked to join the workgroup:

  • African Services Committee
  • Community Service Society of NY
  • God’s Love We Deliver
  • Health People
  • Lenox Hill Neighborhood House
  • Make the Road New York
  • NYC Department for the Aging (DFTA)
  • Ridgewood Bushwick Senior Citizens Council
  • South Asian Council for Social Services
  • Young Adult Institute (YAI) and Premier HealthCare

We are looking forward to working with all these organizations, and sharing their insights and expertise across our network later this year.

In addition to this workgroup, we expect to continue to hear the experiences and voices of all of our community partners in other forums such as the Project Advisory Committee (PAC) meetings and monthly OneCity Health Partner Webinars.

Finally, we are also excited to have Community Service Society of New York (CSSNY) soon begin as our technical assistance partner for community based organization (CBO) capacity building. They will work with us to provide our social service partners with organizational and educational assistance on preparing for value-based payments and improving health outcomes. Thank you to the other two applicants for their expressed interest in this role.

Serving the Patients We Do Not See

“When [marginalized patients] do seek care, it is sporadic,” describes Dr. Dave Chokshi, Chief Population Health Officer, OneCity Health. “They may show up in the Emergency Room (ER), but not to a primary care follow-up appointment. If an ensuing phone call goes unanswered, or their phone is out of service, we label them as ‘lost to follow-up’ and move on to the next patient on the list.”

In his article “The Patients We Do Not See,” recently published by The Conversation, Dr. Chokshi questions the role of the health care system in treating patients who may be sick but don’t seek care.

From social isolation, to the current political climate, to the barriers the health care system itself erects, Dr. Chokshi walks through potential reasons that people don’t actively seek care. One of the most unfortunate aspects, notes Dr. Chokshi, is that the most marginalized patients are those with the greatest unmet needs.

Emphasizing a public health mindset, and moving the locus of accountability for health further into communities, is one solution favored by Dr. Chokshi. Through our transformation initiatives, OneCity Health is actively linking patients to primary care and social services, conducting home visits to kids with asthma and transitioning patients to the community following a stay in the hospital. However, we also need to take the next step, as it is also necessary “to equip patients to be better stewards of their own health,” says Dr. Chokshi.

“Sometimes this involves health care providers, sometimes not. While physicians can’t do it alone, we can lend our voices to those calling for greater outreach, less stigma and protection of the most vulnerable.”

Read the full article here.

Asthma Webinar Recap: Identifying and Addressing the Root Causes of Exacerbations

Thank you to everyone who attended our March 20, 2017 webinar “Asthma Exacerbations: Identifying and Addressing the Root Causes”.

In this presentation we discussed the important role of community health workers (CHWs) and other health care workers in helping patients who have had an asthma exacerbation. During the webinar, we detailed:

  • Why asthma exacerbations occur
  • The role of a CHW in identifying and addressing root causes of asthma
  • How CHWs can use alerts in the GSI software program to find out when a patient with asthma was in the hospital or emergency department

Miss the webinar? The slides are available to view here.

You can also view a recording of the webinar here. We will embed it below soon.

Upcoming Asthma Webinar: Identifying and Addressing the Root Causes of Exacerbations

Asthma is the third leading cause of hospitalization among children under the age of 15 in the United States, often times because families may not understand how to reduce triggers. So how can we help reduce the number of asthma attacks?

Please join OneCity Health for a webinar on March 20, 2017 entitled “Asthma Exacerbations: Identifying and Addressing the Root Causes” where we will discuss how community health workers (CHWs) and other health care workers can best help patients who have had an asthma exacerbation.

Dr. Luis Rodriguez, Chief, Department of Pediatrics, NYC Health + Hospitals/Woodhull and Elvira Fardella-Roveto, MSN, FNP, Home Care Director, St. Mary’s Healthcare System for Children will join us on the webinar to discuss:

  • Why asthma exacerbations occur
  • How CHWs are identifying and addressing the root causes of asthma
  • How CHWs can use alerts in the GSI software program to find out when a patient with asthma was in the hospital or emergency department

Participants will be able to ask questions via the chat function during the webinar. For our partners who cannot attend live, this webinar will be recorded and posted to our website.

Here is how to join the webinar:

Monday, March 20, from 3 p.m. – 4 p.m. EST
WebEx Meeting Link: click here
Audio Connection: 1-855-282-6330 US TOLL FREE
Access Code: 737 673 960

About the Presenters
Luis Rodriguez, MD, FAAP, Chief, Department of Pediatrics, NYC Health + Hospitals/Woodhull
As Chief of NYC Health + Hospitals/Woodhull’s Department of Pediatrics, Dr. Rodriguez is responsible for overseeing the complete range of services the hospital provides to younger patients. He is particularly concerned with efforts to increase wellness and manage chronic conditions – such as asthma – that are having a devastating impact on our communities. Dr. Rodriguez has served in several leadership roles in the American Lung Association at the city, state, and regional levels. He has volunteered with the Open Airways in School Program which teaches New York City elementary school children with asthma about their disease, and in the “Rostros de la Gripe” campaign encouraging the Hispanic community to get their annual influenza vaccine.

Elvira Fardella-Roveto, MSN, FNP, Home Care Director, St. Mary’s Healthcare System for Children
Ms. Fardella-Roveto, has been with St. Mary’s Healthcare System for Children for over seven years, serving as Director of Professional Services & Home Care Administrator. In her role, Ms. Fardella-Roveto oversees all aspects of the Special Needs Certified Home Health Care Agency, which helps families care for their special needs child at home. Her additional responsibilities include ensuring the provision of quality care to clients and families, managing a staff of skilled professionals and maintaining compliance with Department of Health regulations. Ms. Fardella-Roveto has an extensive background in healthcare, having held positions in various healthcare settings. She has experience with private duty and high tech nursing, case management, community health, and education.

OneCity Health Partner Reporting Manual Version 3.0 Now Available

To assist our partners with completing all remaining metrics that are included in their Schedules B for DSRIP Year Two (DY2, which runs through March 31, 2017), we have developed Version 3.0 of the OneCity Health Partner Reporting Manual.

The updated manual replaces Version 2.1 and reflects the following updates:

  • How to report on the remaining Comprehensive Schedule B metrics due in the fourth quarter of DY2 (through March 31, 2017)
  • Reporting requirements for three additional distinct Schedules B (Asthma Community Health Worker, Cultural Competence & Health Literacy [CCHL] Organizational Self-Assessment, CCHL Focus Group Facilitation)
  • Additional reporting instructions for both the Health Home At-Risk and Care Transitions Amendment Schedules B, which were included in the previous version of the manual

Page one (1) of the manual includes a summary of the updates in this version, including specific page numbers of updated content.

We will further discuss the updated OneCity Health Partner Reporting Manual and upcoming reporting requirements with our partners on tomorrow’s OneCity Health Partner Webinar.

Click here to download version 3.0 of the OneCity Health Partner Reporting Manual.

November GSI Trainings

As we discussed in our October 11, 2016 OneCity Health Partner Webinar, we are continuing to schedule trainings for our partners in GSIHealthCoordinator (GSI), a care coordination and population health management platform. We have added a number of new sessions for November at locations across the city; please visit our Events Calendar to view the dates and register.

There are two training options for partners contracted to provide asthma services. Please review carefully before selecting a GSI training.

    1) Partners with a distinct Schedule B for asthma community health workers – This training is for asthma community health workers who have OneCity Health patients within their caseloads and their respective supervisors
    2) Partners with the Asthma-Clinical project included in their Comprehensive Schedule B – This training is for primary care staff who are implementing the Asthma-Clinical project

To attend a session, partners need to register ahead of time and must have a signed Schedule B with OneCity Health.

Partner Webinar: Coordinating Patient Care

Thank you to our partners who attended today’s OneCity Health Partner Webinar: Coordinating Patient Care: GSI and the RHIO.

For our partners who were unable to view the webinar, the slides are available to view here.

Please also view the webinar here:

Our partners should keep in mind next steps:

    • Due by October 14, 2016: 13 Comprehensive Schedule B metrics
    • Due by October 15, 2016: Five Patient Engagement metrics
    • Continue to attend monthly OneCity Health Partner Webinars. Our next one will be November 15, 2016
  • Our support desk is also available for questions.

    We look forward to continuing to engage with our partners on future webinars.

    Community Health Workers’ Role in Improving Kids’ Asthma

    When children come to the Emergency Department suffering from an asthma attack, doctors and nurses provide treatments that give immediate relief. There are sometimes difficulties or barriers to keeping children from having asthma attacks at all – families may not understand how to identify and reduce asthma triggers such as dust, mold or vermin in the home, and children and their families may have difficulty getting or properly taking medications that can prevent attacks.

    Asthma is the third leading cause of hospitalization among children under the age of 15 in the United States. At OneCity Health, our goal is to make sure that children and their families don’t need to come to the Emergency Department or spend the night at the hospital because of asthma attacks. Through the Delivery System Reform Incentive Payment (DSRIP) program, OneCity Health is beginning to connect primary care physicians with community health workers and home remediation services, helping the professionals across these organizations work together to care for patients with asthma.

    After identifying a patient with frequent or severe asthma attacks, clinical care teams will refer patients to a community health worker (CHW) to meet with the patient and complete an asthma assessment. Community health workers will reinforce recommendations from the clinical team, including correct use of medications. In addition, the community health workers will conduct home visits to evaluate the home environment for asthma triggers, such as mold or dust. Based on the assessment, the CHWs can provide materials such as pillow cases or cleaning supplies, instruct families in home-cleaning strategies, or engage home remediation services to provide professional cleaning.

    Through ongoing home visits and phone calls with patients’ families, communication with the patient’s clinical care team, and care coordination that is supported by care management software, the CHWs will continue to engage patients and help them to manage their asthma.

    In order to begin, we have shared Schedules B with our partners who employ CHWs. They should sign them right away so we can begin to match them with clinical sites.

    Please review our previously released asthma care model webinar to learn more.

    Asthma Project Update & Introduction to Care Models

    Calling all community-based partners with experience in outreach and education!

    Project Participation Opportunities allow partners to indicate their interest in supporting one or more facets of project implementation. On December 2, OneCity Health released a Project Participation Opportunity to identify community-based organizations interested in partnering with clinical sites for our project on Asthma Self-Management. The role of the community-based organizations will be to develop or expand community health worker programs. Community health workers will be a key component of the integrated health delivery system for asthma as well as for future projects in other clinical areas, such as cardiovascular health.

    OneCity Health recognizes the need to support an increase in the community health workforce throughout the city. We strongly encourage community-based organizations throughout the city, with expertise in outreach and education, including those with staff such as health educators, case managers, or peer educators, to reply to this Project Participation Opportunity for Asthma by filling out the brief Project Interest Form. For the many New York City neighborhoods where community health worker programs will need to grow, OneCity Health anticipates supporting training needs for community health workers within its partner organizations.

    For questions regarding this Project Participation Opportunity, please email DSRIPSupport@nychhc.org with the subject line ‘Asthma Project.’ Questions will also be answered during the related webinar on Tuesday, December 15 from 9AM-10AM. Please see details below:

    OneCity Health Asthma Project: Project Participation Opportunity Webinar

    Tuesday, December 15, 2015, 9AM -10AM
    Meeting Number: 736 037 937
    Meeting Password: DSRIPASTHMA
    Join WebEx
    Join by Phone
    Dial-in: 1-877-922-9506
    Participant code: 1523959#

    Introduction to Care Models

    As you know, OneCity Health will implement eleven projects to achieve system transformation through DSRIP. For eight of these projects, an important step in planning and implementation design is the creation of a care model. A care model is a framework for project implementation across the PPS which describes partners’ roles, responsibilities, resources, and relationships for each project.

    Each care model includes:

    • State-defined project requirements and additional core objectives
    • Key concepts underlying project design
    • Roles and responsibilities for clinical partners in project implementation
    • Relationships between different partner types as we build strategies for integrated delivery to support the projects
    • Anticipated training and resource needs from OneCity Health Services (CSO) in support of project implementation

    Each Care Model is reviewed and recommended by the OneCity Health Care Models Committee and subsequently approved by the Executive Committee. Detailed implementation plans require an understanding of the local environment and will be developed in conjunction with partners. OneCity Health will initiate a series of webinars to present care models to the partner network and the public starting in January 2016.

    Care Model Webinar Dates


    Asthma: January 6, 2016, 2PM – 3PM
    Palliative Care: January 13, 2016, 2PM – 3PM
    Cardiovascular Health: January 20, 2016, 2PM – 3PM

    Please stay tuned for further details as we move closer to these dates! For questions about care models, please email DSRIPSupport@nychhc.org with the subject line ‘Care Models.’

    Important Dates

    Project Participation Opportunity to provide palliative care education in the primary care setting: Proposal due December 11 (Click here for more details.)

    OneCity Health Asthma Project: Project Participation Opportunity Webinar: December 15, 9AM -10AM (See details above.)

    Project Participation Opportunity to create or expand community health worker programs for the asthma self-management project: Project Interest Form due December 23 (Click here for more details.)