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.)
$50,000 (over eight months)
To support planning for a major pilot project in Queens to test strategies to improve connectivity to and use of healthcare by the chronically homeless
Center for Urban Community Services, Inc.
To support evaluation of the impact of Janian Medical Care on patient health outcomes, healthcare utilization, and expenditure
The Child Center of NY, Inc.
$100,000 (over eighteen months)
To improve access to primary care services for children in Queens communities by embedding pediatricians and hosting pediatric, family, and internal medicine residents within a community-based mental health and family services setting
Community Health Project, Inc. dba Callen-Lorde Community Health Center
To support planning and capacity building aimed at addressing current and future challenges to sustainability and growth
Community Healthcare Network
$150,000 (over eighteen months)
To support a study comparing three models of collaboration between a community-based health clinic and community-based organizations addressing social determinants of health
Fountain House, Inc.
$200,000 (over two years)
To develop a value-based payment relationship with Medicaid Managed Care in support of a community-based integrated model of social, mental health, and primary care for individuals with serious and persistent mental illness
God's Love We Deliver, Inc.
To help support the technology expansion and program evaluation capacity required for program success and systems change efforts related to Medicaid coverage of medically tailored meals
Human Services Council of New York City, Inc.
$75,000 (over eighteen months)
To bring together a network of health care and social service providers in Central Brooklyn with the objective of facilitating creation of an Accountable Community for Health and Wellness
Institute for Community Living, Inc.
$125,000 (over eighteen months)
To support the development, implementation, and assessment of a model of integrated behavioral and primary health care at a new East New York Health Hub
NYC Health + Hospitals
$200,000 (over two years)
To help support the development, implementation, and evaluation of a Home-Based Primary Care program targeting high-risk home- or nearly home-bound older adult patients
Public Health Solutions
To support efforts aimed at improving outcomes in an IT-based system for referring high-risk, food insecure patients to a network of community-based food and nutrition service providers in the Bronx
Supportive Housing Network of New York, Inc.
To maximize supportive housing opportunities for medically needy homeless people