Ongoing CCHL Self-Assessments, Upcoming Focus Groups, Lay the Foundation for Tailored Care

We serve a variety of diverse populations throughout our network, and to optimally support all patients and clients and strengthen our integrated delivery system, it is critical that we tailor care to meet their social, cultural and linguistic needs.

As part of our efforts to improve cultural competence and health literacy (CCHL), 25 percent of our partner sites (amongst those with a Schedule B to complete the CCHL survey) have completed self-assessments, using the Communication Climate Assessment Toolkit (C-CAT) survey and other tools, to understand the current state, strengths and opportunities for improvement.

However, we still have a long way to go! Additional sites are continuing with the assessment through the month of May. This initiative will provide the OneCity Health network with additional insights on disparities and gaps in service delivery, and an opportunity to promote best clinical and administrative processes to improve them. We would like to thank our partners for their hard work to date surveying staff and patients and laying the foundation for the significant work ahead.

Additionally, 14 OneCity Health community partners will soon begin to conduct focus groups with patients or consumers from our identified priority populations, including uninsured individuals, individuals born outside the United States and individuals with developmental disorders. Feedback from our patients and consumers will add to the data on sites and their staff that we are collecting through the CCHL self-assessments. Our partners will conduct up to 28 focus groups.

We look forward to sharing the results and steps for improvement with our network later this year.

Listening Session Focuses on Unique Health Needs of Patients with Intellectual/Development Disabilities

According to the state’s Department of Health, an estimated one in 21 hospitalizations involve persons with Intellectual/Development Disabilities (I/DD) across New York State. As a special population with a particularly high utilization rate, it is critical that our transformation initiatives integrate specific programs to ensure we meet their unique health care needs, both in the hospital and across community settings, to prevent avoidable hospitalizations.

To that end, OneCity Health hosted an initial listening session with three of our partners – Young Adult Institute (YAI), AHRC NYC and Cerebral Palsy Association of NYS (CP of NYC) – to learn how we can provide more culturally competent care to individuals with I/DD and their families, and share their collective expertise across our integrated delivery system (IDS).

An important first step is to help our partners and providers be aware of and understand the unique health concerns of I/DD patients so they can be proactive with treatment.

“Often times, providers haven’t received training in how to work with I/DD patients,” explained one of our participants. “Not only are there unique ways to communicate with an I/DD patient, but there are different ways to communicate with their support system as well.”

A training curriculum composed of e-Learning modules, in-person sessions or roundtable conversations, along with complementary resources, are potential approaches to begin instruction of clinical staff, noted our participants. These would focus not just on communication to patients and their support systems, but distinguishing intellectual and development disabilities from other behavioral health conditions, to ensure they receive appropriate services.

In addition to helping our partners learn more about the needs of I/DD patients, a secondary component is ensuring that we refer patients to appropriate settings that can manage their unique, long-term health needs and reduce the amount of care delivered in the hospital. One approach we’ll soon engage in with session participants and other agencies is to develop a screening tool for I/DD patients. Concurrently, we have initiated plans to further integrate social service providers and their expertise in transformation work by introducing a closed loop referral system to our network. Within this system, we plan to include partners and providers that are well-equipped to take care of our I/DD patients, which will allow health care delivery sites to access and make referrals to appropriate social and community services.

Thank you to YAI, AHRC NYC and CP of NYC for joining our initial listening session. We continue to look for opportunities to leverage the expertise of our partners and share collective learning across our IDS to improve the care of patients and clients.

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.

OneCity Health Partner Reporting Manual Version 2.1 Now Available

To assist our partners as they continue to complete metrics, we have developed Version 2.1 of the OneCity Health Partner Reporting Manual.

This updated manual replaces Version 2.0 and reflects the following updates:

  • Additional guidance for all Comprehensive Schedule B metrics due December 31, 2016
  • New guidelines on distinct Schedules B, including Health Home At-Risk (HHAR) and Care Transitions Amendment
  • New general reporting guidance; our partners can now answer questions directly through the OneCity Health Partner Portal rather than downloading excel templates for some metrics
  • Updated information on how to resubmit reports

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

Version 3.0 of this manual, with all remaining metrics, including those for distinct Schedules B, will be issued in early 2017.

We will further discuss the updated OneCity Health Partner Reporting Manual and upcoming reporting requirements with our partners on our next OneCity Health Partner Webinar on December 13.

Click here to download version 2.1 of the OneCity Health Partner Reporting Manual.

Achieving Transformation Through Training and Education

As we progress with our transformation efforts, it is essential for our partners to have a shared understanding of the Performing Provider System’s (PPS) goals and how to reach them. To that end, OneCity Health has undertaken numerous activities to date – and will soon launch many others – to help train and educate our partners.

From instructing Transition Management Teams to coaching our partners to utilize the Patient Activation Measure® (PAM®) survey, each OneCity Health initiative has been rooted in engaging our PPS partners with educational materials and technical assistance, which helps our partners:

These are just a few examples; education supports improved patient and population health across our integrated delivery system and could extend to areas such as care management and information technology (IT), among other topics. OneCity Health is investing $50 million in workforce training for our network over the Delivery System Reform Incentive Payment (DSRIP) program to support these efforts.

As we make educational content available or schedule opportunities for instruction, we will reach out to our partners and ensure they are well-positioned to improve patient health. Simultaneously, we will coordinate with our PPS partners’ many training-related assets to encourage best practices and leverage our greatest strengths.

Cultural Competence and Health Literacy Self-Assessments Set to Launch

The continuous demographic changes and diverse communities of New York City highlight the need to assess and improve the care and service delivery that is culturally and linguistically appropriate. OneCity Health, as a part of its health care transformation efforts, is initially investing $1.65 million in a Cultural Competence and Health Literacy (CCHL) initiative.

The CCHL initiative will provide us and our partners an opportunity to identify disparities and gaps in service delivery, and promote best clinical and administrative processes. The information collected will inform how we refine our cultural competency training efforts, workforce development, and evaluation metrics so that together we can continue to identify appropriate programs and other measures to improve access and effectively deliver equitable care.

To begin, we will soon be launching the CCHL site self-assessment for partners that expressed interest via the Project Participation Opportunity (PPO) in September. Over the next six months, 75 partner sites will complete the self-assessment. This initial self-assessment will establish a baseline and current state of each organization’s CCHL strengths and opportunities for improvement. By November 15, 2016 participating partners should receive a Schedule B via DocuSign. The CCHL Schedule B outlines project deliverables; partners should sign as soon as possible to begin.

As a reminder, participating partners will be required to designate a site liaison for each site that will participate in the assessment. The site liaison will be the main point of contact for CulturaLink, a vendor working with OneCity Health to complete the assessments.

For our partners who expressed an interest in facilitating focus groups at their sites, we will reach out to you soon with next steps.

Thank you again to our partners who have chosen to participate in the Cultural Competence and Health Literacy Organizational Self-Assessment. We look forward to beginning!

Agenda for the November 2 City-Wide PAC Meeting

Our next OneCity Health City-Wide Project Advisory Committee (PAC) meeting is Wednesday, November 2, 2016 from 3 p.m. – 5 p.m. in the 12th Floor Conference Room A&B at the Gouverneur Health Center at 227 Madison Street in Manhattan.

Please review this presentation in preparation for our meeting. In addition to highlighting our collective accomplishments, we are seeking our partners’ input on the following topics:

  • Social determinants of health
  • Cultural competency and health literacy

There will also be an opportunity for our partners to network with their fellow Performing Provider System (PPS) partners.

If our partners have any questions or concerns that they would like OneCity Health to also address at our meeting, please feel free to submit them to our support desk in advance of our meeting.

We look forward to seeing our partners on Wednesday!

Partner Feature: Callen-Lorde Community Health Center

In the latest in a series of articles featuring OneCity Health partners, we highlight Callen-Lorde Community Health Center and their role within the OneCity Health Performing Provider System (PPS).

From its initial days as an integrated health clinic, Callen-Lorde Community Health Center, which provides health care and related services to New York’s lesbian, gay, bisexual, transgender and queer (LGBTQ) communities, saw vast demand for mental health services within their primary care clinics.

“Last year we had just two social workers stationed in our primary care clinic that assessed patients and made referrals, and they filled up quickly,” explained David A. Guggenheim, PsyD, Chief Mental Health Officer, Callen-Lorde. “We know that LGBTQ patients experience trauma at higher rates than the general population, and that they can really benefit from therapy and other mental health services.”

Callen-Lorde has since expanded their model to better meet the long-term therapy needs of patients by locating both behavioral health clinicians and psychiatric nurse practitioners within the primary care clinics.

They have moved toward a system in which a patient visits a primary care provider, who conducts an initial assessment. If necessary, a patient is then seen by a therapist for a short period of time through a warm handoff, and patients can sometimes return to primary care to continue with medications prescribed in mental health.

“There is never a gap in care,” said Dr. Guggenheim, “this all begins with, and returns to, the primary care facility.”

Through the Delivery System Reform Incentive Payment (DSRIP) program, Dr. Guggenheim believes Callen-Lorde can improve the value in their model.

“Mental health disorders aren’t like medical conditions such as diabetes, we don’t have great measurements to evaluate patient outcomes. Through DSRIP, we are trying to improve the value of the care patients’ receive by renewing our focus on quality. DSRIP initiatives can help us improve by connecting us with other programs and to help us follow patients to ensure they receive the services they need in a timely manner.”

For our OneCity Health partners that are just beginning to integrate behavioral health with primary care, Dr. Guggenheim recommends a commitment to change throughout the organization. For example, Callen-Lorde recently committed to integrating mental health into all medical team meetings. Meetings are often facilitated by care coordinators with mental health experience to demonstrate the commitment to a new culture.

It is also necessary for an organization to understand and tailor care to each unique set of patients. For example, Callen-Lorde is the largest provider of trans-healthcare in the country, and ensures this community, which faces unique mental health challenges, receives appropriate care right from the start.

“We make sure patients of trans experience feel safe and supported coming to our clinic. We use the right pronouns and ask the right questions in the primary care setting,” said Dr. Guggenheim. “If patients don’t walk into a culturally competent clinic, there is a much higher risk that they won’t receive care.”

Cultural Competence and Health Literacy Focus Groups Project Participation Opportunity

Earlier in September, we shared a Project Participation Opportunity (PPO) with our partners to conduct an organizational self-assessment to identify strengths and areas for improvement in cultural competence and health literacy (CCHL), which is critical for the transformation of our health care delivery system. By participating in the assessment, our partners will gain feedback from their staff on service delivery, and better understand the concerns and perspectives of their patients and consumers.

Today we shared a second PPO with OneCity Health partners to express interest in conducting CCHL focus groups with patients or consumers from our identified priority populations. Feedback from our patients and clients will add to the qualitative data that we are collecting from providers for our CCHL self-assessment.

Our partners can read the Interest Form and express interest here.

Partner Webinar: Improving Access to Care

Thank you to our partners who attended today’s OneCity Health Partner Webinar: Improving Access to Care: Documenting Workflows & Cultural Competence.

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 September 30, 2016: 13 Comprehensive Schedule B metrics

    • Due by October 7, 2016: Complete the Excel template to submit a workforce report. Be on the lookout for the template and instructions via email

    • Due by October 15, 2016: five Patient Engagement metrics


  • Our support desk is also available for questions.

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

    Cultural Competence and Health Literacy Project Participation Opportunity

    The diversity of stakeholders that OneCity Health partners serve highlight the need to deliver culturally competent care and meaningful service that meets their linguistic and communication needs. Only by listening to the perspectives of both staff and patients, and thoughtfully evaluating how we deliver services, can we help eliminate health disparities, and provide optimal health care service encompassing of cultural and health equity.

    As a first step, OneCity Health is identifying partners via a Project Participation Opportunity (PPO) to participate in an organizational self-assessment to identify strengths and areas for improvement in cultural competence and health literacy (CCHL), which is critical for the transformation of our health care delivery system. By participating in this assessment, our partners will gain feedback from their staff on service delivery, and better understand the concerns and perspectives of their patients and consumers.

    The organizational assessment will also help us to establish a roadmap, which will include cultural competence recruitment and training efforts, CCHL workshops and development activities to help our partners meet “best practice” CCHL standards. We will also track cultural competence and health literacy capacity over time, using the organizational assessment as a baseline.

    We will further detail this opportunity in our September 13 monthly OneCity Health Partner Webinar. The deadline for partners to complete the PPO is September 19.