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.)
Breaking Ground Housing Development Fund Corporation (FKA Common Ground Community H.D.F.C., Inc.)
To help support an assessment of health-supportive services
Care for the Homeless
To support the capacity to scale up delivery of primary care to homeless individuals in accord with a coordinated, disease-management, treatment-to-goal model
Center for Urban Community Services, Inc.
To help support the Janian Medical Care Billing Infrastructure Project and its expanded focus on Medicaid billing for psychiatric services
The Child Center of NY, Inc.
$75,000 (over fifteen months)
To support an effort to better address social determinants of health by systematically conducting client needs assessments, referring for services and supports, and collaborating with Northwell Health to host, engage, and leverage the assistance of medical residents in this work
The Children's Health Fund
To utilize a screening tool with homeless families to identify social factors hindering efforts to regain and retain housing, and to develop and pilot a Homelessness Risk Assessment Tool for use by primary care providers to identify and address risk factors of homelessness in their patients
City Futures, Inc.
$50,000 (over eighteen months)
To research, prepare, and strategically disseminate a report on Rethinking New York City's Senior Services: A Blueprint for Improving Services for New York's Fast-Growing and Increasingly Diverse Senior Population
Community Health Project, Inc. dba Callen-Lorde Community Health Center
To help support the continued work of the LGBTQ Shared Services Collaborative in its effort to identify, and plan to address, gaps and unmet needs for support and services related to social determinants of health
Community Healthcare Network
$35,000 (over six months)
To assess needs, explore interest, and plan for a potential pilot project to provide infrastructure and/or capacity support to community-based organizations addressing social determinants of health in collaboration with a community healthcare partner
Corporation for Supportive Housing
$125,000 (over two years)
To implement and promote replication of the Bronx Frequent Users of Hospital Systems (Bronx FUSE) initiative, a collaborative multi-agency effort to identify homeless individuals in the healthcare system and place them in supportive housing
New York Legal Assistance Group, Inc.
To identify and recommend models for the provision of suitable respite for the "medically homeless" in New York City
Sunnyside Community Services, Inc.
To support the Dementia Coach Initiative, a coaching model to build the skills and confidence of home health aides working with clients who have Alzheimer's disease and/or dementia, with the aim of improving client outcomes and employee retention
Supportive Housing Network of New York, Inc.
To help ensure that homeless high-cost Medicaid users are effectively matched with supportive housing units, and strategically prioritized within NYS's Empire State Supportive Housing Initiative
United Hospital Fund of New York
$145,000 (over eighteen months)
For continued support of the Partnerships for Early Childhood Development initiative and the goal of strengthening clinical-community partnerships focused on addressing social determinants of health in early childhood
Urban Pathways, Inc.
$115,000 (over fifteen months)
To connect residents in four supportive housing sites to comprehensive community-based health care and supportive services, provide health education to residents and staff, and seek to reduce inappropriate use of emergency medical resources