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.

CMMI Staff Event Highlights Program Success, Next Steps for ED Triage

Following treatment in the Emergency Department (ED), we can better meet the health needs of some patients through improved care coordination and a variety of other resources. Ranging from primary care follow-up appointments to care management services for patients with ambulatory care sensitive conditions, these programs can also help prevent unnecessary return visits in the future.

Through a Center for Medicare & Medicaid Innovation (CMMI) grant, teams of registered nurses (RNs), community liaison workers, physician advisors and pharmacists began providing similar support in six NYC Health + Hospitals facilities in September 2014. This program resulted in a steady decrease in ED revisits within 30 days of discharge over the course of the intervention period, and highlighted the need to include a social work component to better address patients’ social determinants of health. In May, CMMI staff gathered for an afternoon of training, team-building activities and a discussion on the success to date, lessons learned and next steps.

CMMI staff engage in a team-building activity, attempting to balance a marshmallow using just dry pasta, tape and string

We plan to apply the findings under this grant regarding patient impact and quality outcomes to OneCity Health’s ED Care Management initiatives, through which we will focus on the highest-needs, highest-utilizing patients instead of all patients with ambulatory care sensitive conditions. Staff will continue to connect patients to primary care, while standardized workflows will help them to better identify providers with capacity, as well as other appropriate outpatient services. Their work will also include developing patient care plans, follow-up phone calls and, when appropriate, home visits, as well as medication reconciliation coordinated through the pharmacist and linking patients to community care management.

Madeline Rivera, RN, MS, CCM, Executive Director, Care Management, OneCity Health, leads a discussion on care management and how it will be incorporated into the Emergency Department

In addition to connecting patients to primary care, ED staff can also refer patients to care management services such as NYC Health + Hospitals/At Home, which includes primary care-care management, and our Health Home At-Risk program. Patients will also be linked to OneCity Health partners who provide community support, such as helping patients adhere to their treatment plan and other follow-up services.

OneCity Health partner 1199 SEIU facilitated an interactive care management training at the event, focused on identifying and addressing patient’s social determinants from the Emergency Department

Thank you to our CMMI teams for their enthusiasm and participation at our recent event. We look forward to building off their success and expanding our support for patients in the comings months.

New York State SBIRT Resources Available to OneCity Health Partners

The New York State Office of Alcoholism and Substance Abuse Services (OASAS) is offering technical assistance resources and trainings to help our partners implement the Screening, Brief Intervention and Referral to Treatment (SBIRT) program.

Below please find complete details about SBIRT and how to access these resources. Our primary care partners that are Integrating Primary Care with Behavioral Health can report on their participation in any of these trainings through metric PM024 in their Phase 2 Comprehensive Schedule B.

SBIRT Technical Assistance Opportunity

What is SBIRT (Screening, Brief Intervention and Referral to Treatment)?
SBIRT is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related health consequences, disease, accidents and injuries. Risky substance use is a health issue and often goes undetected. For more information on SBIRT please visit and watch the following video:

What resources are available for SBIRT implementation?
NYS OASAS has a time-limited technical assistance opportunity for hands-on, intensive consultation, guidance, and training to emergency departments, primary care practices, and other health delivery practitioners implementing SBIRT across New York State. Technical assistance supports various stages of implementation and includes:

  • Advice and guidance on all aspects of readiness and practice implementation using OASAS resources and based on best practices;
  • education and training on SBIRT;
  • on-site implementation support, as needed.

NYS OASAS aims to advise individual sites in becoming fully operational and sustainable by:

  • Identifying barriers to implementation;
  • identifying strategies to overcome barriers;
  • assessing current workflows and assisting in reconfiguration;
  • creating and reviewing process maps;
  • gauging readiness;
  • and developing individualized project management tools such as project timelines & work plans.

To request OASAS SBIRT technical assistance and/or training, email

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.

MAX Program Accelerates DSRIP Transformation

We just hit the accelerator on one aspect of our transformation efforts!

Teams from NYC Health + Hospitals/Bellevue and NYC Health + Hospitals/Lincoln kicked off their participation in the New York State Department of Health Medicaid Accelerated eXchange (MAX) Series Program last week, an innovative 6-month program that puts front-line clinicians from both hospitals in a position to lead rapid change and help achieve Delivery System Reform Incentive Payment (DSRIP) program goals.

Both “Action Teams” will quickly implement changes to improve care for the relatively small proportion of inpatients who account for a disproportionate amount of utilization and cost (often referred to as ‘super utilizers’). The program, which includes other hospitals in addition to the two teams from NYC Health + Hospitals, includes learning sessions, follow-up webinars, and periods of time to conduct small tests of change. Subsequently, through the MAX Train the Trainer Program, additional staff from NYC Health + Hospitals/Lincoln, NYC Health + Hospitals/Bellevue and OneCity Health, as well as from Xincon Home Health Care Services, one of our community partners, will work with our teams to help sustain and proliferate these changes throughout our Performing Provider System (PPS).

Teams from NYC Health + Hospitals/Bellevue and NYC Health + Hospitals/Lincoln attend their first MAX workshop

Among other areas of focus, the team from NYC Health + Hospitals/Lincoln plans to immediately initiate a pilot for an interdisciplinary 15-minute daily huddle about admitted high utilizing patients, while the team from NYC Health + Hospitals/Bellevue plans to increase appropriate referral patterns to NYC Health + Hospitals home health, telehealth, and health home programs. To begin, both Action Teams participated in their first of three full-day workshops, which help build skills and capacity for process improvement at the local level. Both teams generated ideas for ‘quick wins’ and set priorities to be completed during the ‘Action Period’ before the second workshop in mid-February.

This iteration of the MAX Series Program concludes in April, with the goal of sustaining the gains attained from the effort and disseminating best practices to our other partners.

Since the MAX Series Program focuses on improving care for super utilizers, it supports and aligns with our transformation goal of transitioning patients to an appropriate primary care and community setting. Past program participants have been able to generate positive results including measurable reductions in Emergency Department and inpatient utilization.

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.

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.

Initiating ED Care Triage Phase One

As we noted last week, we recently initiated phase one of our ED Care Triage project at four NYC Health + Hospitals facilities.

Due to accessibility, convenience, cost and other factors, patients regularly seek care at the Emergency Department (ED) for minor illnesses or complications from a chronic illness, which can often be treated in alternative settings. OneCity Health’s ED Care Triage project works in collaboration with primary care and community partners, to ensure that those who frequent the ED are connected to ongoing care.

Our goal in the initial phase of project implementation is to successfully link patients who are treated and released with a primary care physician for follow-up care, and to emphasize the value of primary care to patients in managing their ongoing health needs. Success depends on providing convenient access to high-performing primary care teams, and a significant portion of our Delivery System Reform Incentive Payment (DSRIP) program transformation efforts are focused on primary care improvements. Given that improved access to timely appointments will be necessary to begin guiding patients away from the ED for non-urgent care, we will also utilize a call center to streamline appointment scheduling and consistently assess our network for providers accepting new patients.

It will also be essential for our community-based partners to support these efforts by educating patients about primary care and promoting alternatives to the ED in non-urgent situations. Moreover, it will also be necessary for partners to provide culturally-competent counseling to patients in the ED to help redirect them toward primary care.

Phases two and three of ED Care Triage will be implemented later, and will focus on patients with chronic and severe illnesses who could benefit from care management services. To learn more about this project, please view our recent webinar, or feel free to email us with questions at with the subject line “ED Care Triage”.

OneCity Health Care Models Webinar – ED Care Triage

The goals of the ED Care Triage project are to strengthen primary care linkage for patients presenting to the Emergency Department (ED), and to support transitions to outpatient services for high-risk patients by means of ED transitions management. Please join this Webinar to learn more.

Monday, April 11th from 2 p.m. – 3 p.m. EST
WebEx Meeting Link: click here
Audio Connection: 855-282-6330 US TOLL FREE
Access Code: 735 676 794