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.

Semester Two of New York State’s VBP University

The New York State Department of Health has launched Semester Two of VBP University, which is an online, educational resource created to raise awareness, knowledge and expertise in the move to value-based payment (VBP).

Topic areas in Semester Two include governance, stakeholder engagement, business strategy, finance, and data. The curriculum for Semester Two includes videos on each of the topics as well as detailed guidance documents targeted towards Primary Care Physicians, Behavioral Health Providers, and Community Based Organizations.

Semester Two also includes VBP arrangement fact sheets to serve as a continuation of the arrangements curriculum in Semester One. The fact sheets provide an overview of each of the NYS VBP arrangements, including the types of care included in the arrangement, the method used to define the attributed population for the arrangement, calculation of associated costs under the arrangement, and the quality measures recommended for use in the arrangement.

To begin Semester Two, click here.

For more information on VBP University and Semester One, click here.

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.

PCMH Learning Collaborative Webinar on Care Coordination Available to View

We recently hosted our latest Patient-Centered Medical Home (PCMH) Learning Collaborative, a webinar focused on care coordination, for our primary care partners. Our primary care partners learned strategies to improve communication and coordination between providers, and implement systems to better share information, which leads to improved access and higher quality of care for patients. The Learning Collaborative included sample documentation and workflows to help partners better understand best practices.

Miss the webinar? Click here to review the slides, or watch the recording below:

This session was the fourth installment in our series of Learning Collaboratives for primary care partners, which is a part of our efforts to assist 54 sites in the OneCity Health network toward achieving PCMH recognition. Past events have focused on population health management, care management and team-based care and access. Our fifth and final PCMH Learning Collaborative will be an in-person session this October. Stay tuned for registration details.

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

New in NEJM Catalyst: OneCity Health Article on the link Between Coverage Expansion and Delivery System Reform

Under the Patient Protection and Affordable Care Act (ACA), 32 states expanded Medicaid and millions of individuals gained coverage through health insurance exchanges. Provisions in the Affordable Care Act also supported delivery system reform with a strong focus on proactive, community-based care. For safety net providers such as NYC Health + Hospitals —those that by mission or mandate see all patients, regardless of their ability to pay—these two policy objectives are closely linked. As we describe in an article published yesterday in NEJM Catalyst: progress on delivery system reform is maximized when it stands on the shoulders of coverage expansion.

In their article “Coverage Expansion and Delivery System Reform in the Safety Net: Two Sides of the Same Coin,” the authors* describe how maintaining—and optimally, growing—our insured population is crucial in order to take care of those who are still uninsured, but it also is important for our system’s transformation efforts. For example, they discuss how expanding access to high-quality primary care, with integrated behavioral health services, is a linchpin of delivery system improvement. But hiring more primary care clinicians, launching collaborative care programs, and establishing linkages between hospitals and community health centers all require capital investment which stem from coverage expansions.

However, due to recent political developments, this initial progress is still vulnerable. Further progress will depend on keeping the ACA’s health insurance expansion in place.

Click here to read the full article.

* Jeremy P. Ziring, AB, Data Analyst; Kathleen S. Tatem, MPH, Data Analyst; Remle Newton-Dame, MPH, Director of Healthcare Analytics; Jesse Singer, DO, MPH, Assistant Vice President, Care Models and Analytics; and Dave Chokshi, MD, MSc, Chief Population Health Officer, all of OneCity Health

OneCity Health Program Awarded Top National Quality Honor for Targeting Depression

NYC Health + Hospitals has been awarded the 2017 Gage Award for Innovation and Excellence from America’s Essential Hospitals for implementing collaborative care for depression in the primary care setting, a OneCity Health initiative. The Gage Award is the preeminent national recognition for outstanding work at safety-net health systems around the country, and the award earned by NYC Health + Hospitals is its highest in the “Improving Quality” category.

Through its collaborative care program for depression, NYC Health + Hospitals, our largest partner, has significantly increased psychiatric consultations and treatment for depression in primary care, more than tripling the rate of depression improvement among patients enrolled in the program. In 2015, the public health system screened about 225,000 adult primary care patients for depression—more than 90 percent of patients who visited a NYC Health + Hospitals site. Nearly 15,000 of those patients—6.7 percent—screened positive. The program’s key clinical outcome metric focused on the depression improvement rate, which increased from 17.7 percent in the second quarter of 2015 to 57.6 percent in the first quarter of 2016.

“Across NYC Health + Hospitals, we’ve sought to meet patients where they are by coordinating care for medical and behavioral health conditions in a single setting,” said Dr. Dave Chokshi, Chief Population Health Officer, 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 program.

A poster on OneCity Health’s collaborative care program was displayed at a session at America’s Essential Hospitals VITAL2017 Conference. Integrating behavioral health and primary care is an important OneCity Health initiative, and the collaborative care program demonstrates the positive impact on patients’ health

“We’re honored to receive this award, which recognizes the dedicated work of our frontline staff to identify and manage patients with depression in primary care,” said Dr. Jesse Singer, Assistant Vice President of Care Models and Analytics, OneCity Health.

Depression affects 13 percent of Americans and 20 percent of Medicaid recipients in their lifetimes. However, when mental health specialists are not co-located in the primary care setting, only 10 percent of patients follow-up on a referral to a provider.

The collaborative care program for depression was launched under the New York State Hospital Medical Home Demonstration Project in 2014. NYC Health + Hospitals implemented a two-step process to better identify and treat patients with depression. First, the system began universal depression screening for adults in medical and primary care clinics. Second, patients who screened positive for depression were enrolled in the collaborative care program to receive treatment right in the primary care setting. The system’s goal is to ensure that at least 50 percent of patients enrolled demonstrate clinically significant improvement in depression symptoms.

“To ensure patients are receiving excellent care, we provide training and coaching to staff on the ground in depression screening and evidence-based treatment interventions,” said Jessica Black, MPH, MSW, Collaborative Care Program Manager, OneCity Health, who accepted the award on behalf of the health system at a ceremony in Chicago. “We also generate data to support patient outreach and treatment workflows. A newsletter and monthly webinars serve as vehicles to share best practices, such as the warm handoff amongst collaborative care teams.”

Congratulations to the OneCity Health Collaborative Care Team for earning a 2017 Gage Award for Innovation and Excellence from America’s Essential Hospitals

“The collaborative care program has had a significant impact,” said Dr. Michelle Izmirly, Consultant Psychiatrist, NYC Health + Hospitals/Lincoln. “Our new workflows ensure we begin to speak with patients who are depressed, but who have never talked to anyone about it before, thinking their condition was normal or not treatable. Our nurses and social workers ensure follow-up occurs, breaking down barriers that once prevented this type of care.”

To learn more about the collaborative care program, please view the following video:

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.

Utilizing eConsult to Improve Access to Specialists from Primary Care

An underlying theme of our transformation initiatives is increasing value for patients, and ensuring they receive the right care at the right place at the right time.

In their recent case study, published in the New England Journal of Medicine’s NEJM Catalyst, Hannah Byrnes-Enoch, MPH, Program Manager, Ambulatory Specialty Care, Jesse Singer, DO, MPH, Assistant Vice President, Care Models and Analytics, and Dr. Dave Chokshi, Chief Population Health Officer, all of OneCity Health, addressed one particular aspect – the challenge facing patients and primary care providers in accessing timely, affordable specialty care.

“Improving our ability to deliver specialist expertise in lower-cost settings for more patients is critical to our mission as a safety-net health system,” said the authors. “Changes in the health care landscape, particularly an increase in the number of uninsured patients, will make access to specialist care in the safety net more challenging for patients.”

Focusing on NYC Health + Hospitals, they identified opportunities for change. These include:

  • Identifying instances where a patient’s needs can be met in the primary care setting in conjunction with a specialist’s input and guidance
  • Increasing access to specialty care based on the urgency of the patient’s need

To make progress, our team sought to determine whether the eConsult concept, sometimes termed eReferral or eCR, could be integrated into NYC Health + Hospitals’ Electronic Health Record (EHR) system. Their goal was to improve provider-to-provider communication and make it easier for primary care providers and specialists to communicate about and co-manage patients when appropriate. Through the EHR, a specialist would review all incoming referrals, responding electronically when appropriate and requesting the patient to be scheduled for a face-to-face visit if needed.

While the full case study details how they executed the pilot, initial results are encouraging. Early data and feedback from pilot clinics show that the eConsult workflow is contributing to improved access to specialty care and clinical recommendations for patients. There were over 6,000 referrals placed in an eConsult and triaged to a specialist in the pilot. Among these, 70 percent were deemed appropriate for an in-person visit and triaged by urgency, while the specialist provided immediate guidance to the primary care provider for the remaining 30 percent.

Dr. Chokshi and his team are continuing to refine the eConsult model to further improve patient communication and scheduling processes. Read the full article to see the lessons learned and other next steps.

PCMH Recognition at NYC Health + Hospitals Demonstrates Improved Care, Significant Return on Investment

Since last summer, we have been assisting 52 of our OneCity Health primary care partner sites to achieve Patient-Centered Medical Home (PCMH) recognition to ensure that New Yorkers have access to high-quality primary care.

Similarly, over the past year, NYC Health + Hospitals, our largest partner, has been on a journey with 32 of its primary care facilities to renew their Level 3 PCMH status, which is the highest level of recognition conferred by the National Committee for Quality Assurance (NCQA). As our primary care partner sites continue their certification process, the work completed at NYC Health + Hospitals demonstrates the ultimate value of these efforts, both in improved care for patients and a significant return on investment.

Achieving PCMH recognition does not mean construction of a physical space; instead, it is a care model that emphasizes patient-centered access, improved care coordination and enhanced communication. Rather than a patient feeling that his or her care is fragmented, the PCMH model supports patients and families/caregivers in self-management and shared decision making. First, to improve access for patients, NYC Health + Hospitals launched centralized, borough-based call centers to help patients more easily schedule appointments across the system.

Next, it enhanced convenience for patients to access primary care.

“For continuity of care, patients can now access their primary care provider (PCP) by phone for appropriate follow-up care without needing to take time off from work or spend money on transportation to visit one of our practices,” said Rebecca Miller, Director, Primary Care Transformation, NYC Health + Hospitals.

NYC Health + Hospitals’ work toward achieving PCMH certification has not only improved patient care, but has also increased revenue. Following PCMH certification, the New York State Department of Health (NYSDOH) provides incentive payments for certain patient populations, including Medicaid Managed Care (MMC) and Medicaid Fee-for-Service (FFS). After accounting for expenditures such as those made to the NCQA and staff time devoted to the recognition process, NYC Health + Hospitals determined that achieving PCMH certification led to net revenue of $18.3M for fiscal year 2015 and $16.8M for fiscal year 2016.

Moreover, due to increased payment rates from the NYSDOH under the Level 3 2014 PCMH certification standards, NYC Health + Hospitals projects a total net revenue of $84.3M over the next three years (FY’17-FY’19).

OneCity Health is continuing its investment of $1.8M in primary care transformation for our network, not including NYC Health + Hospitals. As NYC Health + Hospitals demonstrates though, our investment in the patient-centered medical home model can yield significantly more revenue for our partners, as well as drive transformation in patient care and improve coordination throughout our developing integrated delivery system.

Agenda for Wednesday’s PAC Meeting

We look forward to seeing our partners at Wednesday’s City-Wide Project Advisory Committee (PAC) meeting at the Brooklyn Public Library.

Here is the agenda for the 3 p.m. meeting:

  • Welcome
  • Networking
  • Follow up from November 2, 2016 PAC Meeting
  • Updates:
    • Status of Project Implementation
    • OneCity Health’s Midpoint Assessment
    • Phase II Contracting
    • Social Service Integration
  • We Need Your Input:
    • Facilitation of Referrals: What are the types of questions that facilitate effective referrals?
    • Performance Management: Request for partners interested in being part of a work group to improve PPS approach to performance monitoring
    • GSI Development: Request for partners to nominate staff for participation in GSI user acceptance testing
    • Understanding the Needs of Primary Care Partners: What technical assistance and support services do these partners need?
  • Upcoming Events and Deadlines

For complete details on the location and travel instructions, please visit our Events Calendar.

As a reminder, PAC meetings are important opportunities for partners to share their experiences with project implementation, provide input into our planning, design and evaluation activities, and get to know fellow OneCity Health partners.