New York–Presbyterian Hospital PPS, in Northern Manhattan, South Bronx, Manhattan and Western Queens, has approximately 80 collaborators including: 14 PCMHs and 50 specialty clinics in its Ambulatory Care Network; emergency departments and inpatient units (behavioral health, medicine and surgery); and a small number of closely connected independent community physicians and FQHCs. The PPS has invested in the expansion of Primary Care to include Nurse Practitioners (Psychiatric and Primary Care), Social Workers, Community Health Workers (CHWs), Peers, and other field-based staff to meet the needs of the members.

Overall Assessment: The Plan is focused, cohesive and addresses its entire network. The largest portion of PC network is within its institutional framework. Leadership committees have good representation from Primary Care. Both direct and indirect support is given to Primary Care, though overall investment to date seems low. No detail on whether PCP recruitment will occur and if so, whether the workforce budget will be used in this effort.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • The PPS region includes areas that are designated both as (1) Health Professional Shortage areas for primary care and as (2) Medically Underserved Areas.
  • 371 primary care physicians, with 88.6% accepting new Medicaid members.
  • Of the 371 providers, 22.5% offer after hours care and 25.3% of these primary care physicians are at sites that are designated 2011 PCMH Level 3.
  • All practices are currently accepting new members and offer some after–hours access
  • If preventable emergency department utilization were reduced by 25% over five years, this would mean that 4,546 patient encounters would now need to be supported by the primary care system annually.
  • PC strategy includes:
    • Connection to Health Information Exchange (HIE) Tools
    • Expanding access to Primary Care at 2 Behavioral Health Sites
    • Expansion of hours at NYP Ambulatory Care Network (ACN) Sites
    • Collaboration with Non–Primary Care Providers
    • Implementing Open Access to Primary Care
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • For the 14 New York–Presbyterian Hospital ACN primary care practices, the NYP Office of Community Health & Development is actively pursuing NCQA 2014 Level 3 PCMH
  • For the 4 independent community physicians, the NYP PPS has contracted with the Primary Care Development Corporation (PCDC) to provide support for their NCQA applications.
  • For the 4 federally qualified health centers (FQHCs), the PPS is currently providing regular check–ins and support to FQHC PPS members.
  • The PPS has fostered a close relationship with the New York City Primary Care Information Project (PCIP), which keeps PPS abreast of new resources.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Integrating all collaborators into Healthix RHIO; Integrating CHWs, Peers, and other Field–Based Staff into Allscripts care management platform; Integrating Substance Use and Behavioral Health Resources into Practices Improving Communication across ED, Acute Care, and Outpatient Settings.
  • The PPS Executive Committee, the Governance Committees, Project Leads and Clinical Operations Committees all include Primary Care Representatives.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Beginning its investigation into achieving 80% level–1 VBP for its members
  • Completed VBP survey with its membership
  • Collaborating closely with NYP/Queens PPS on the VBP strategy, which includes:
    • Education on (1) NYS VBP Roadmap, (2) Contracting considerations, and (3) Performance measurement and 4) assistance navigating NYS data resources
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • Direct investment in workforce to support PCMH - Care mangers, social workers, CHWs
  • In–Kind Investment in 14 NYP/ACN PCMHs with several FTEs
  • $60K contract with Primary Care Development Corporation for 4 community physicians
  • Workforce training
  • $270K/year Primary Care clinician time to serve as Project Leads
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Finalizing contract with NYSPI to place PC Nurse Practitioners at two community–based mental health practices
  • Developing ties via Healthix with community–based behavioral health providers
  • Embedding behavioral health resources and SUD screening & treatment into practices
  • Embedding depression care management using IMPACT Model into new practices
  • Participated in MAX series on behavioral health integration.