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 help create a conceptual model of care for 100-125 homeless individuals with the primary goal to change their utilization behavior and improve their health outcomes
Catholic Charities Brooklyn and Queens
To help support the Outreach & Integration program (formerly Parish & Community)
Children's Defense Fund - New York
To help support CDF-NY's work in research, writing, public education, coalition building, and policy development with regard to how school-based health services should be designed and implemented in New York City; a series of issue briefs will be developed providing recommendations on the construction of healthcare service delivery models in schools
Coordinated Behavioral Care, Inc.
$100,000 (over eighteen months)
To help support the planning and early-stage development and testing of a "1-800-CBC" call center and related work to build programmatic capacity for a move beyond care coordination into a model for integrated multi-agency service delivery focused on behavioral health and, particularly, the population targeted by NYS's soon-to-be-launched Medicaid Health and Recovery Program (HARP)
The Institute for Family Health, Inc.
$100,000 (over eighteen months)
To help pilot test a protocol to screen patients in primary care settings for social factors that may impact their health
Jewish Association for Services for the Aged
To continue to support program development and outcome tracking competencies, exploration and establishment of chronic disease self-management capacities, and efforts to pilot a new managed care partnership model
Montefiore Medical Center
To support the Montefiore School Health program in its effort to advance utilization of the Patient-Centered School-Based Health Center quality standards as the basis for City, State, and Federal reimbursement for health care delivered within a School-Based Health Center under a "value based" payment structure
United Hospital Fund of New York
$150,000 (over fifteen months)
To support development and testing of a revised Health Indicators-Performance Improvement (HI-PI) program aimed at improving the ability of community-based organizations to collaborate with health care providers in serving older adults
United Jewish Appeal-Federation of Jewish Philanthropies of New York, Inc.
To help support the participation of community-based agencies in year three of the Community Health Initiative