OneCity Health is the largest PPS in NYS with over 635,000 attributed Medicaid members and a partner network of approximately 250 organizations. The PPS serves the public hospital system in the Manhattan, Bronx, Brooklyn and Queens. Network includes 1292 primary care providers (PCPs) [~780 PCP FTEs] with 191 sites that provide PC services (of which 133 have fewer than five physicians or NPs onsite). PPS´s geographic coverage area includes MUA/P and HPSAs. Twenty community primary care sites either have, or are in the process of, attaining NCQA 2014 Level 3 certification. Thirty–eight sites are currently NCQA PCMH 2011 Level 3 certified. Overall Assessment: Plan is extensive and thorough, with tables that make it easy to understand the PPS´s PC strategy. Plan states that PCPs have begun to receive funds, including payment for engagement, but dollar amount is not stated.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • External research/analysis has projected the need for 203 additional PCP FTEs by 2020 in the four boroughs served by the PPS.
  • Defining a strategy to expand, engage and train workforce to meet future needs.
  • Forming new partner relationships to increase PC capacity and working with existing partners to expand capacity.
  • Improving process for referrals and scheduling appointments.
  • Working with community organizations to reach out to people in need of PC who are not connected.
  • Using community experts and organizations to provide services that address social determinants of health.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Contracted with PCMH consultants to assist 92 PC sites in achieving NCQA 2014 Level 3 certification.
  • Currently has a team of 10–15 ambulatory care transformation coaches to provide technical assistance (TA) to individual sites.
  • Establishing learning collaboratives for ongoing improvement.
  • Helping with connectivity for exchange of health data, including providing TA to help practices acquire EMRs.
  • Developed a training strategy addressing drivers of health disparities.
  • Developed a profile of the current workforce and projected needs over the next 4 years.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • PC will play a central role in the IDS, with an integral role in many of the PPS´s clinical initiatives. Each initiative strengthens the continuum of PC and ensures meaningful linkages to secondary and tertiary services, community organizations, and community health workers. These initiatives include, but are not limited to, PC and behavioral health (BH) services integration, CVD management in the PC setting, palliative care (led by PC), ED care triage and linkage to PC, and care transitions management.
  • PCPs are represented on the PPS´s governing bodies, including the Executive Committee, Care Models Committee, Stakeholder and Patient Engagement Committee, and Bronx and Manhattan Hub Steering Committees.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Strategy to enable PCPs to participate in VBP successfully includes:
    • assessing PC readiness for VBP (survey),
    • providing TA and training to help practices achieve PCMH certification,
    • supporting practices in connecting to QEs to enable data exchange,
    • coaching and establishing learning collaboratives for best practice sharing,
    • designing the PPS´s data and reporting requirements to help partners adapt to VBP reporting requirement
    • improving value and reducing avoidable costs, and
    • helping PCPs function as high performing teams with the necessary information, connectivity, care models, training, and connections into the community.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • Funds are distributed to partners based on metrics, number of attributed patients, and project selection.
  • Total funds flow available to partners for the current contract phase (through 3/31/17) is $55 million. Additional funds support PCPs through PCMH technical assistance and licensing fees, IT support, and consulting help with PC/BH co–location. PCPs have begun to receive funds, including payment for engagement.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Conducting universal depression screening for adults in PC
  • Developed a team of collaborative clinical care coaches
  • Contracting with consultants to provide TA to PC and BH sites to develop the ability to provide collaborative care
  • Working with CBOs to reach people who are not seeking PC or BH services, and who may be disconnected from the traditional health care delivery system
  • Providing care management for high–risk patients with a BH diagnosis who do not currently qualify for health homes
  • Increasing mental health and substance abuse literacy among NYC middle and high school students by linking schools to hospitals and community–based providers to promote partnership and collaboration in addressing student needs