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.)
The Bridge, Inc.
As a final grant to support an increased rate of formal enrollment in CBC's Health Home, as well as quality-assurance activities aimed at improving quality of care and avoiding preventable hospital use by Health Home enrollees
Jewish Association for Services for the Aged
To provide support for development of a model of patient-centered care that will maximize the potential for reimbursement for the full range of JASA services by Managed Care plans
Lenox Hill Neighborhood House, Inc.
$25,000 (over six months)
To support research, analysis, and partner cultivation to assess the potential for successful partnership with health providers related to care transitions for frail older adults
Primary Care Development Corporation
$250,000 (over two years)
To help support creation of a systematic approach to clinician engagement in health homes, while launching a learning community and advisory board to begin testing and disseminating PCDC care coordination tools more broadly
United Jewish Appeal-Federation of Jewish Philanthropies of New York, Inc.
To help support the participation of community-based agencies in year two of a three-year Community Health Initiative