Partner Webinar: HIV, RHIO Connectivity and Training to Support Implementation

Thank you to our partners who attended today’s OneCity Health Partner Webinar: HIV, RHIO Connectivity and Training to Support Implementation.

We apologize for the technical difficulties, and appreciate your patience as we attempted to work through them. For our partners who were unable to view the webinar, or were unable to connect to the revised dial-in, the slides are available to view here.

If we are able to use a recording of the webinar, it will be embedded here as soon as it is available.

Our partners should keep in mind next steps:

  • Due July 14, 2017: PM002.1 (skilled nursing services), and PM022.1 (Integrated Palliative Care Outcome Scale assessments)
  • July 17: Listening session on changing healthcare landscape in Queens. Registration details are on our website
  • July 21: Listening session on changing healthcare landscape in the Bronx. Registration details are on our website
  • July 26: Listening session on changing healthcare landscape in Manhattan. Registration details are on our website
  • July 27: Listening session on changing healthcare landscape in Brooklyn. Registration details are on our website
  • Due July 27, 2017: PM003.1 and PM012.1 (asthma) and PM010.1 and PM011.1 (Care Transitions)
  • Due July 27, 2017: Seven Patient Engagement Metrics
  • Due July 31, 2017: PM005.1 (HIV)
  • August 7, 2017: Last day for our partners to remediate Phase I metrics and earn the money associated with those metrics in their Phase I Comprehensive Schedules B
  • August 8, 2017: Attend our next monthly OneCity Health Partner Webinar. The webinar will be held from 2 – 3:30 p.m. Details are on our website Events Calendar
  • Due August 15, 2017: PM016 (NPI Survey) and PM029 (Phase III Contracting Survey) – all partners are required to complete these

In addition, if our partners are interested in learning more about our HIV resources, such as the HIV Coalition, we recommend they reach out to our support desk.

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

New Palliative Care Training Opportunities

We are pleased to announce a new training opportunity available to all OneCity Health partners in partnership with The Center to Advance Palliative Care (CAPC), a national organization dedicated to increasing the availability of quality palliative care services to people with serious advanced illness.

This opportunity offers free online continuing medical education (CME) or continuing education (CE) units for 35 courses on palliative care, ranging from basic front-line education to technical courses on symptom management and prescribing. They provide staff with access to tools, training and technical assistance aimed at improving both clinical as well as operational skills for the delivery of palliative care, treatment and support services. Membership to CAPC is free and is required to access these resources including:

  • Access to CAPC faculty: Call into Virtual Office Hours with CAPC faculty to ask questions in real-time about billing, staffing, clinical protocols, etc. or network with peers by posting a question to the faculty-moderated forum
  • Learn new skills: Earn free CME/CE units in courses including pain management, symptom management, communication skills, and palliative care program design
  • Download ready-to-use tools: Access over 500 tools and resources including budget templates, sample job descriptions, assessment instruments, and the comprehensive palliative care reference library
  • Discover emerging best practices and innovative programs: Attend twice-monthly webinars

This opportunity is available to all OneCity Health partners including community-based organizations, and long-term care, hospice, and primary care providers. In order to receive membership and access to this exciting training opportunity, our partners should complete and submit the attached template with contact information for all staff members they would like to access CAPC resources to the OneCity Health support desk at ochsupportdesk@nychhc.org.

Shortly thereafter, our partners’ staff will each receive an email from CAPC containing registration information to begin accessing these resources.

Please reach out to our support desk with any questions about registering for CAPC resources.

Palliative Care Best Practices Guide

When Ariane Garcia, a patient representative at an NYC Health + Hospitals/Gotham Health center in the Bronx, sought to engage with more patients about the value of designating a health care proxy as part of OneCity Health’s palliative care initiative, her first step was to actually encourage her colleagues to do their own advance planning.

“A conversation for designating a health care proxy provides patients with the right choice and to understand the value in their choice,” explained Garcia. “Therefore, it is important that staff understand why advance planning is important, especially when they are encouraging patients to designate a health care proxy.”

Garcia’s next step was to create a standard workflow. She identified staff at a variety of points across a patient’s care experience, including reception, registration and finance, and made sure they were trained to provide patients with initial information about designating a health care proxy. Additional staff would then follow-up with the patient to further discuss and encourage the process.

“Our staff are encouraged,” said Garcia, “They understand it is an important aspect of patient care.”

This is just one approach to supporting primary care teams in implementing advanced planning. For our partners who are beginning to implement this project, we summarized this and other lessons learned into a Best Practices Summary, which is available to download here. This helpful guide also includes example workflows and patient education materials from a variety of NYC Health + Hospital facilities.

Guiding Patients to Assign a Health Care Proxy: An Essential Conversation

The following article appeared in the September 20, 2016 edition of the NYC Health + Hospitals Insider, and highlights our initial palliative care work at our largest partner.

Annie, 72, receives primary care at an NYC Health + Hospitals/Gotham Health center in the Bronx. With no immediate threat to her health, Annie was surprised when her physician asked if she wanted to authorize a health care proxy who could make medical decisions on her behalf if she lost the ability to make them herself.

“I would always get busy and forget about looking into it on my own,” said Annie. “But it was very easy and convenient to do while I was at the health center with someone who could walk me through it.”

Through the state’s Delivery System Reform Incentive Payment (DSRIP) program, primary care staff and physicians throughout NYC Health + Hospitals are having conversations with patients about the value of designating a health care proxy. These conversations, which were typically limited to hospital environments, are helping primary care teams better understand a patient’s values and preferences and is the first phase in a broader effort to integrate palliative care into the primary care setting.

“Advanced planning, which includes having patients designate a health care proxy, helps us strengthen the communication between our patients and their care teams so, together, we can better coordinate and manage the patient’s chronic illness or pain regardless of whether they are being served in our community based health centers, a hospital-based ambulatory care clinic or in one of our hospitals,” Dr. Christina Jenkins, CEO, OneCity Health Services.

Although Annie had heard about health care proxies before, she wasn’t sure how to proceed. After her NYC Health + Hospital physician explained the details, she agreed it was time to name one. That’s where the work of patient representatives like Ariane Garcia come in.

“When I meet with the patient, I explain to them that completing a proxy is an essential part of their health care,” said Garcia, who helped Annie through the designation process. “Not only does it protect their rights, it assures that they will receive their desired medical care, and it will help to eliminate a burden on their family to make decisions later.”

While advanced planning is especially important for patients who are older or may have a chronic illness, our health care teams are extending this support to more and more adult patients who can benefit from goal-setting and designating a proxy.

Joylaine Reid, PCA discusses designating a health care proxy
Joylaine Reid, PCA discusses designating a health care proxy

“Ninety-nine percent of patients tell me they are too young,” said Joylaine Reid, PCA, who works in the new patient adult primary care practice at NYC Health + Hospitals/Kings County. “And I always remind them that they are not too young, though, to end up in a situation where they can’t speak for themselves, and nobody knows their wishes.”

Reid knows first-hand the consequences when a patient does not have a health care proxy. Her own family experienced it when her father became ill and no one had control over the situation. He subsequently passed away.

“It is important to put in place someone you can trust. I’m never afraid to get in front of a crowd of patients to encourage it,” Reid said.

Integrating Palliative Care into Primary Care

One of our achievements at the conclusion of DSRIP Demonstration Year One was surpassing our initial goal for our palliative care project. OneCity Health successfully engaged over 500 patients at a dozen NYC Health + Hospitals neighborhood health centers and acute care facilities with simple advance care planning.

Our initial success laid the foundation for our larger transformation efforts. Soon we will begin additional interventions with our community partners aimed at ensuring that our patients with chronic symptoms and advanced illnesses are appropriately managed in the primary care setting.

Each patient can have a unique set of needs. Some may require functional support, such as physical therapy, while others may need pain management, the services of a home attendant or transportation to appointments. For patients with an advanced illness, planning discussions may determine that patients need legal assistance or spiritual support. Integrating palliative care programs into primary care appointments better enables primary care teams to understand and manage patients with chronic and serious illnesses, before they seek aggressive care or hospitalization for their pain or other distressing symptoms. Primary care teams can also assist with advance planning and coordinating appropriate resources for patients with an advanced illness, to ensure that their needs are properly addressed.

We have begun training our primary care partners to initiate planning discussions with patients, but it will take the involvement and integration of our numerous community partners into our palliative care project that will help enable its success. By increasing access to palliative care in the primary care setting, and with the support of our community partners, we can help to address the medical, psychosocial and practical needs of our patients.

To learn more about this project, please view our recent webinar, or feel free to email us with questions at DSRIPSupport@nychhc.org with the subject line “Palliative Care Project”.

Entering DSRIP Demonstration Year Two

Thank you to everyone who attended our Project Advisory Committee (PAC) meetings last month in one of the four borough-based hubs, as well as those who completed the pre-PAC survey. For those who couldn’t attend, you can view the presentation here. If you did attend one of the recent meetings, please complete this optional post-PAC meeting survey. We value your feedback and use it to shape the agenda at future PAC events.

At both the meetings and in the pre-PAC survey, you emphasized a desire to learn more about Delivery System Reform Incentive Payment (DSRIP) program implementation and funds flow. Since we just concluded DSRIP Demonstration Year One (DY1, April 1, 2015 – March 31, 2016), we feel this is an appropriate time to review our recent milestones and what is on the horizon regarding these two topics.

Project Implementation: We successfully administered over 11,000 Patient Activation Measure (PAM®) surveys as part of Project 11. Over the next 12 months we have committed to administering 55,000 PAM® surveys and in linking at least that many people to high quality care. We are confident that in collaboration with NYC Health + Hospitals and our community partners we can meet this goal.

In addition, we are also proud to announce that we surpassed our initial goal for our palliative care project, as we successfully engaged over 500 patients with simple advance care planning in the primary care setting. This was just the first wave; moving forward, we’ll continue to implement additional interventions with our community partners aimed at ensuring our patients’ symptoms and advanced illnesses are appropriately managed in the primary care setting.

We have also initiated pilots for multiple other DSRIP clinical projects: 1) ED Care Triage, which begins the effort to connect patients with primary care from the Emergency Department; 2) Care Transitions, for which our goal is to provide a supportive transition to the community for patients who were admitted to the hospital and reduce readmissions; and 3) Health Home At-Risk planning, in which the objective is to extend care management services equivalent to the NYS Health Home program.

You can review the care model webinars on these clinical projects here.

Funds Flow: On April 4, we launched the Master Partner Data Survey to finalize our funds flow. If your organization has signed a Master Services Agreement (MSA) and provides clinical and social services, regardless of whether you bill for Medicaid, then your organization should have received the Data Survey. Please contact us immediately if you believe you should complete the Data Survey. Once it is complete, we will develop a more encompassing Schedule B for your organization, which will detail project deliverables and payments.

Expect more information in the coming weeks on project status and implementation as we advance into DSRIP Demonstration Year Two (DY2, April 1, 2016 – March 31, 2017). As always, if you have feedback or questions, please feel free to email us at DSRIPSupport@nychhc.org.

Survey Results from our January 2016 City-Wide PAC Meeting

We would like to thank everyone who completed a survey at last month’s city-wide Project Advisory Committee (PAC) meeting. Approximately 60 people attended the meeting, and 22 provided feedback. As we continue to unroll Delivery System Reform Incentive Payment (DSRIP) program initiatives, these surveys provide valuable guidance on how best to engage our partner network.

Our next slate of Hub PAC meetings commences next week – the Bronx PAC meeting will be Tuesday, March 1, at 5:30 p.m. at the Lincoln Hospital Auditorium – and the survey results will help guide the agenda. Below please find the results; we hope attendees take a few minutes to fill out the surveys at future meetings as well, or provide feedback at any time by sending us an email at DSRIPSupport@nychhc.org.

Question One 20160225_Question 1

The city-wide PAC agenda included a presentation with updates on Project 11, asthma home-based self-management and palliative care in the primary care setting, all of which are currently underway, as well as a few notes on OneCity Health’s governance structure. However, some respondents indicated that they are eager for more on-the-ground specifics regarding the projects, which we plan to detail at future meetings and on our website as projects continue to unfold.

Question Two 20160225_Question 2
Question Three 20160225_Question 3

Following the presentation, attendees split into four breakout groups for interactive discussions on measuring success and building cultural competency within our network. The discussion was lively, but we understand the groups were large and time was limited. Moving forward, we’ll continue to adjust the size of the groups to better engage all of our partners.

Additionally, while we always welcome feedback and agenda items for our PAC meetings via DSRIPSupport@nychhc.org, we’ll begin to use pre-surveys to identify topics our attendees would like to discuss at upcoming meetings. As noted earlier, as we begin to implement more projects, the discussion with shift toward these specific initiatives.

20160225_Question 4

Respondents provided a rich variety of topics for future meetings. Moving forward, both at PAC meetings and on our website, we plan to continue to detail specific projects, highlight our partners and provide clear and timely information regarding the DSRIP process and payment structure.

Question Five 20160225_Question 5

Thanks to everyone who attended! We hope to see everyone at our Hub meetings in March.

Update on the Master Services Agreement Process

OneCity Health has made significant progress in the Master Services Agreement (MSA) contracting process since commencing in early November. As of February 2016, approximately 80 percent of MSAs have been fully executed. We are very appreciative of our partners who have signed the MSA and are continuing to work with our remaining partners to complete this phase of the contracting process.

Concurrently, we are moving the next stage forward, which involves the development of project-specific schedules that define our and our partners’ commitments related to implementing a project and details the total funding and payment mechanisms a partner is eligible to receive for implementing a particular project. Please note that a partner must sign an MSA before they are eligible to receive a project schedule.

In December 2015, OnceCity Health began distributing the first schedules to partners, which stemmed from the project participation opportunity (PPO) for Project 11. A PPO is an opportunity for partners to assist in the initial implementation of a project.

To date, approximately 80 percent of project schedules for Project 11 partners have been distributed. OneCity Health is currently developing schedules for a variety of additional projects including asthma (community based organizations, primary care physicians [PCPs]), palliative care (training, PCPs) and primary care core competencies (PCPs). Expect to hear more from us on these in the coming weeks.

Each of our partners has unique strengths and programs to support building an integrated delivery system to meet the needs of our communities. The MSA is not just the first step toward achieving our larger goals, but is also an opportunity for increasingly more partners to participate as we continue to deploy more projects. We look forward to finalizing this process over the coming weeks.

Partners Gather for First City-Wide PAC Meeting of 2016

OneCity Health hosted a lively and interactive city-wide Project Advisory Committee (PAC) meeting this week, as partners from across the city met to hear the latest updates on New York State’s Delivery System Reform Incentive Payment (DSRIP) program, and discuss meaningful ways to improve partner and consumer engagement.

Dr. Christina Jenkins, President and CEO, OneCity Health Services, kicked off the event by highlighting the progress in a number of projects. As part of Project 11 – which seeks to engage and educate uninsured and Medicaid low- and non-utilizers – OneCity Health has trained 60 unique community partners to administer the Patient Activation Measure® (PAM®) survey to uninsured individuals. Projects focusing on asthma home-based self-management and palliative care in the primary care setting are also underway, with participation opportunities recently issued to community partners. In regards to governance, Dr. Jenkins also noted that to improve focus and inclusion, the Stakeholders Committee will now include a distinct Workforce Committee comprised of labor and other organizational partners.

Following the presentation, attendees split into four groups for an interactive discussion focused on two important topics:

  • How can OneCity Health develop a framework to best measure the success of its Performing Provider System (PPS) in the community?
  • Focusing on the variety of cultures throughout the communities in the PPS, what is the best strategy to catalog current community-based interventions that succeed in delivering care in a way the patients trust and appreciate?

Through the group discussions, partners provided very helpful feedback. To improve cultural competency, ideas included training effective navigators, identifying successful community-based organizations and sharing their knowledge with other partners, and coordinating peer-to-peer conversations. In regards to measuring success, OneCity Health partners suggested moving past delivering health advice, to better focus on screenings and referrals so patients continue to engage with the system.

OneCity Health will continue to discuss both topics with partners at hub-level PACs and other workgroups, and report back on a framework at future city-wide PAC meetings. We also appreciate our partners taking the time to fill out the post-event surveys, and will incorporate their feedback into future meetings. In the meantime, if you have suggestions for either topic, or general thoughts about the PAC meeting, please email us at any time at DSRIPSupport@nychhc.org with the subject line “City-wide PAC.”

Thank You to Our Partners

We would like to extend our gratitude to Kevin Muir of CAMBA, Hira Mir of VillageCare, Chris Norwood of Health People, Maria Guevara-Friedman of Northern Manhattan Perinatal Partnership and Humberto Brown of the Arthur Ashe Institute for their time in reviewing the initial draft of the Project 11 guidelines. Their valuable insight helped guide the current phase of Project 11.

Reminders: PAM Trainings and DSRIP Webinars


OneCity Health Patient Activation Measure® (PAM®) Trainings
For community members interested in participating in Project 11, please see an earlier newsletter about the opportunity to administer the Patient Activation Measure® (PAM®) survey. Below is a list of upcoming PAM trainings. Please RSVP to PAM-Training-DSRIP@nychhc.org as soon as possible. Trainings will take place at 199 Water Street, 31st Floor, New York, NY 10038.
February 8th, 2016, 2PM – 5PM
February 26th, 2016, 2PM – 5PM
March 14th, 2016, 2PM – 5PM
March 31st, 2016, 9AM – 12PM

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

DSRIP Care Model Webinars
Below are links to the materials presented during past webinar sessions. Webinar recordings will be made available shortly.
Asthma Care Model
Palliative Care Model
Cardiovascular Health Care Model
For more information about care models, please click here.

Transition to Value-Based Care: DSRIP & the Workforce

To achieve New York State’s Delivery System Reform Incentive Payment (DSRIP) Program goal of reducing avoidable hospital use (emergency department and hospital admissions) by 25 percent in New York State by the end of the program’s life, the State’s healthcare delivery system, including its workforce, will need to evolve. This evolution from a volume to value-focused healthcare delivery system will also require the expansion of access to community-based primary care and other social and family support providers, resulting in the need for both the addition of new members and retraining and redeployment of some existing members of the workforce in order to provide high quality, culturally competent healthcare and services.

Therefore, a key component of the DSRIP Program is the development of a workforce strategy which aims to:

  • Define the target workforce state;
  • Assess the current workforce state;
  • Develop a gap analysis of baseline to target workforce state;
  • Conduct a workforce impact analysis;
  • Determine an estimated workforce strategy budget to accommodate new hires, redeployment and retraining of staff;
  • Develop a workforce transition roadmap that incorporates the gap analysis; and
  • Develop a plan to address training needs around prevention, integrated care, community-based outreach, care coordination, patient engagement and self-management.

To collaborate on these workforce aims, OneCity Health has partnered with the Bronx Partners for Healthy Communities, NYU Brooklyn Bridges and Community Care of Brooklyn Performing Provider Systems under the auspices of a workforce consortium. The workforce consortium seeks to jointly plan, design, implement and analyze the results of the current and target workforce states; share as appropriate some aggregated data allowing for a citywide view of the current and future health workforce states; and minimize duplication of effort across shared partners. In December 2015, the workforce consortium selected BDO Consulting, LLC as the vendor that will support the development and execution of a workforce strategy individually and collectively with the members of the workforce consortium.

OneCity Health is committed to engaging all stakeholders, including our labor partners, to identify strategies to minimize the impact of the DSRIP Program on the existing health workforce, and to develop robust retraining and redeployment strategies that enable timely, meaningful and sustained response to the rapidly-changing healthcare environment.

In the next few weeks, BDO Consulting, LLC will commence outreach to OneCity Health partners to complete the assessment of your current health workforce. Additional details will be forthcoming.

Palliative Care Project Participation Opportunity for Primary Care Providers

We are pleased to introduce a Project Participation Opportunity for primary care providers who are interested in integrating palliative care into the PCMH Model. This Project Participation Opportunity is intended for OneCity Health community partners only; NYC Health + Hospital sites should not submit an expression of interest and will be engaged in discussion around implementation through a separate process.

Primary care sites that participate in this project must commit to meeting 2014 NCQA Level 3 PCMH standards and/or the standards established by the state for the Advanced Primary Care Model by the end of DSRIP Year 3. Primary care staff who participate in this project will attend targeted trainings to increase role-appropriate palliative care skills and competencies, as required by protocols developed by the PPS. Please note that this is not a procurement process, but rather a way for OneCity Health partners to self-identify interest in participating in project implementation.

Interested partners should review the Palliative Care-Primary Care Project Participation Opportunity and submit the Palliative Care Project- Primary Care Interest Form to OneCity Health at DSRIPSupport@nychhc.org by January 27, 2016 with the subject line “Palliative Care Project – Primary Care.” OneCity Health will respond to all expressions of interest by February 5, 2016.

An expression of interest through the completion of the interest form will provide OneCity Health with an understanding of interest and resources within our PPS partner network for both early and future roll-out of this program to primary care sites.

Questions regarding this Project Participation Opportunity should be sent to DSRIPSupport@nychhc.org with the subject line “Palliative Care PPO Questions.” We will respond to your inquiries promptly.

We will also hold a webinar to take questions about this opportunity on Friday, January 22nd at 10 AM. The webinar is not mandatory for participation in this project or submission of interest.

Informational Webinar for Palliative Care Project Participation Opportunity WebEx Address
Friday, January 22nd at 10 AM
Meeting number: 734 032 514
Join by phone: +1-855-282-6330 US TOLL FREE
Access code: 734 032 514

Asthma Project Participation Opportunity for Primary Care Providers

We are pleased to introduce a Project Participation Opportunity for primary care providers that treat pediatric and/or adolescent populations and wish to participate in the project, “Expansion of the Home Environmental Asthma Management Program to Reduce Avoidable ER Use and Hospitalizations Related to Asthma by Means of Implementing or Expanding Home-Based Services.” This Project Participation Opportunity is intended for OneCity Health community partners only; NYC Health + Hospital sites should not submit an expression of interest and will be engaged in discussion around implementation through a separate process.

In this project, clinical sites will be partnered with and work in coordination with home-based services (community health workers and home remediation services) for the management of patients with poorly-controlled asthma. A pool of trained community health workers (CHWs) from community-based organizations in our PPS network will support this project. A separate Project Participation Opportunity for CHW services for the asthma project was released on December 2, 2015 and concluded on December 23, 2015. Please note that this is not a procurement process, but rather a way for OneCity Health partners to self-identify interest in participating in project implementation.

Interested partners should review the Asthma Project—Primary Care Project Participation Opportunity and submit the Asthma Project – Primary Care Interest Form to OneCity Health at DSRIPSupport@nychhc.org by January 27, 2016 with the subject line “Asthma Primary Care.” OneCity Health will respond to all expressions of interest by February 5, 2016.

An expression of interest through the completion of the interest form will provide OneCity Health with an understanding of interest and resources within our PPS partner network for both early and future roll-out of this program to primary care sites. Timelines for implementation at clinical sites will be affected by the availability of community health workers to support the program.

Questions regarding this Project Participation Opportunity should be sent to DSRIPSupport@nychhc.org with the subject line “Asthma Project-Primary Care PPO Questions.” We will respond to your inquiries promptly.

An informational webinar regarding this project participation opportunity was held. Click here for the materials presented.

OneCity Health Patient Activation Measure® (PAM®) Trainings

For community members interested in participating in Project 11, please see an earlier newsletter about the opportunity to administer the Patient Activation Measure® (PAM®) survey. Below is a list of upcoming PAM trainings. Please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. Trainings will take place at 199 Water Street, 31st Floor, New York, NY 10038.

January 29th, 2016, 9AM – 12PM
February 8th, 2016, 2PM – 5PM
February 26th, 2016, 2PM – 5PM
March 14th, 2016, 2PM – 5PM
March 31st, 2016, 9AM – 12PM

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

DSRIP Care Model Webinars

Below are links to the materials presented during past webinar sessions. Webinar recordings will be made available shortly.

Asthma Care Model
Palliative Care Model
Cardiovascular Health Care Model

For more information about care models, please click here.

Upcoming Citywide Project Advisory Committee (PAC) Meeting

OneCity Health’s Project Advisory Committees (PACs) serve as indispensable advisory forums as we develop approaches to improve the health and well-being of New Yorkers. In addition to advising programmatic processes and guidelines for the design, implementation, monitoring and evaluation of DSRIP projects, we also seek meaningful ways to improve partner and consumer engagement. We are actively seeking agenda items from our partners for the next citywide PAC meeting scheduled for January 26, 2016 at Brooklyn Borough Hall. Please email DSRIPSupport@nychhc.org with the subject line ‘PAC Agenda Suggestions’. We look forward to seeing you on January 26, 2016. All are welcome!

Citywide PAC Meeting

  • Date & Time: Tuesday, January 26th, 2016, 6:00PM- 7:30PM
  • Location: Brooklyn Borough Hall, 209 Joralemon St, Brooklyn, NY 11201

Important Updates for Asthma, Primary Care Transformation, and Palliative Care

Community Health Workers for Asthma Patients: Project Participation Opportunity

We are pleased to announce a Project Participation Opportunity for Asthma for our community-based partners that wish to implement or expand community health worker programs, in support of the project “Expansion of Asthma Home-Based Self-Management.” OneCity Health anticipates funding new or expanded community health worker programs in order to meet the needs of patients treated within our clinical network. OneCity Health recognizes community health workers as trained personnel with understanding of local communities who will provide home visits in support of existing clinical, care management, and social services. Please note that this is not a procurement process, but rather a way for OneCity Health partners to self-identify interest in participating in project implementation.

We strongly encourage community-based organizations who may be interested in this program to fill out and return the brief Partner Interest Form by Wednesday, December 23, 2015. An optional informational webinar will be held on Tuesday, December 15, 2015, 9am -10am (details to follow via email). An expression of interest in this opportunity will allow OneCity Health to include a partner organization in its understanding of the resources within our PPS partner network for both early and future roll-out of community health worker services.

Questions regarding this opportunity will be addressed during the scheduled webinar. In addition, partners may address questions to OneCity Health at DSRIPSupport@nychhc.org with the subject line “Asthma”.

Update on Primary Care Transformation and the Patient Centered Medical Home

Coordinated, accessible, and culturally competent primary care is a foundational component of OneCity Health’s DSRIP program. Our primary care partners play a critical role in enabling seamless care transitions, managing chronic illnesses, and integrating across the medical and behavioral health services spectrum. One approach to achieving this vision for primary care delivery is the Patient Centered Medical Home (PCMH) model. PCMH is a nationally recognized model for transforming the organization and delivery of primary care. The model focuses on five key functions and attributes:

  • Comprehensive Care
  • Patient-Centered Care
  • Coordinated Care
  • Accessible Services
  • Quality and Safety
A core requirement of the New York State DSRIP program is that all participating primary care providers in the PPS achieve accreditation from the National Committee for Quality Assurance (NCQA) for 2014 PCMH Level 3 Standards by the end of DSRIP Year 3 (March, 2018).

Many of the primary care partners in the OneCity Health PPS are already well on their path to PCMH transformation. One of the ways OneCity Health will support our participating primary care partners on this journey is to offer technical assistance through partnerships with organizations that have deep experience in primary care transformation.

On Monday, November 16, 2015, OneCity Health released a Request for Proposals (RFP) for vendors to support primary care transformation at participating partner sites within the PPS. For more information on this RFP, please refer here.

Please stay tuned for more information about how OneCity Health will be working with its primary care partners to ensure robust, accessible, and coordinated primary care for all patients across our integrated delivery system.

Palliative Care: Project Participation Opportunity

OneCity Health’s palliative care project aims to help primary care teams integrate palliative care skills into their practices, including advance planning, symptom management, goal-setting, and complex care planning for patients with serious advanced illness.

OneCity Health’s Project Participation Opportunity for Palliative Care seeks partners with specialized expertise both in palliative care and in clinical education to provide training and coaching services to primary care teams. While we anticipate that our journey towards an integrated delivery system will include many roles for palliative care services, the focus of this opportunity is specifically on training and coaching in the primary care setting. Please note that this is not a procurement process but rather a way for qualified OneCity Health partners to self-identify interest in supporting training and coaching.

The deadline for an expression of interest is Friday,December 4, 2015; a proposal of no more than 5 pages is due on Friday,December 11, 2015. Please direct all communications regarding this project, including questions as well as expressions of interest and proposals, to DSRIPSupport@nychhc.org, with the phrase “Palliative Care” in the subject line.

NYC Health + Hospitals’ Medical-Legal Partnership

NYC Health + Hospitals is working in collaboration with LegalHealth to provide legal support to patients to improve health outcomes by addressing social and economic factors such as income, education, and employment. Click here to learn more.