Expand and strengthen quality out-of-hospital health care for the most underserved and vulnerable populations.
- Increase in New Yorkers benefitting from primary care from a “Patient-Centered Medical Home” or comparable out-patient community-based provider
- Increase in New Yorkers benefitting from coordinated care, care management, and/or multi-disciplinary services and supports provided in an accessible community- or home-based setting, with a focus on programs targeting individuals living in poverty, with multiple chronic or behavioral health conditions, and/or who are transportation-challenged, including frail elders
- Increase in New Yorkers receiving services and supports aimed at reducing unnecessary hospital admissions, readmissions, or emergency room use, and successfully transitioning patients into out-of-hospital community-based care and care management
(Priority will be given to programs capable of being sustained with earned or public sector revenue, producing outcomes of long-term value in a short time, and/or of reducing cost to the system while maintaining or improving quality of care to the individual.)
Care for the Homeless
To expand the integrated model of condition-specific care management at the Susan’s Place open access health center, integrating behavioral health diagnoses, with the primary goal of changing acute care utilization, improving patient engagement, and ultimately improving health outcomes
Center for Urban Community Services, Inc.
To provide a second year of capacity-building support to maximize billing efficiency under Medicaid Managed Care and other contracts in an effort to achieve a diversified funding base for medical and psychiatric services delivered to homeless and formerly homeless individuals
Community Health Care Association of New York State
$35,000 (over six months)
To enhance the reporting and data-analytics capabilities of the Center for Primary Care Informatics (CPCI) in preparation for value-based payment and a role supporting Independent Practice Associations (IPAs) comprised of Federally Qualified Health Centers (FQHCs)
Community Health Project, Inc. dba Callen-Lorde Community Health Center
To support a project of the LGBTQ Services Collaborative to collect and analyze client data derived from a shared intake form across the three agencies with the aim of better addressing social determinants of health
Institute for Community Living, Inc.
$125000 (over eighteen months)
To support the development and implementation of a model of integrated behavioral and primary health care -- to be delivered by two co-located agencies working in partnership -- at a new East New York Health Hub
The Institute for Family Health, Inc.
To assess the impact on patient well-being and provider behavior of systematic screening for social determinants of health at a primary care center in the South Bronx
Mount Sinai Hospital/Mount Sinai Adolescent Health Center
To test a psycho-social and behavioral health intake assessment instrument designed to improve adolescent health care in an urban community health center practice
The New School/Center for New York City Affairs
To support reporting, policy analysis, and advocacy on the under-capacity of children's behavioral health services and to inform implementation of NYS's plan to strengthen and enhance these services through Medicaid redesign
Service Program for Older People, Inc.
To support model refinement and the documentation of outcomes in this partnership effort to provide coordinated physical and mental health care to homebound seniors
Sunnyside Community Services, Inc.
To support the introduction of one-on-one coaching for home health attendants assigned to clients with Alzheimer's Disease/dementia
Supportive Housing Network of New York, Inc.
To identify and promote policies and practices with the potential to maximize health care resources in supportive housing
United Hospital Fund of New York
To support the Partnerships for Early Childhood Development initiative that aims to strengthen clinical-community partnerships focused on addressing social determinants of health in early childhood
Urban Pathways, Inc.
$100,000 (over fifteen months)
To support the second phase of a project aiming to demonstrate the benefits of providing on-site health and wellness education and support for formerly homeless adults living in supportive housing residences