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Press Releases

32 NYC Health + Hospitals Primary Care Clinics Earn the Highest Level of Patient-Centered Medical Home Recognition

Official recognition reflects that patient care is better coordinated and more convenient

Additional revenue from related incentive payments expected to be nearly $60 million over two years

Nov 21, 2017

New York, NY

NYC Health + Hospitals today announced that 32 of its hospital and community-based primary care clinics received the highest-level Patient-Centered Medical Home (PCMH) recognition for meeting rigorous national standards and establishing a model to deliver patient-centered, coordinated, and convenient health care services to New Yorkers.

Thirty-two health system primary care clinics received the National Committee for Quality Assurance’s PCMH 2014 Level 3 recognition, which reflects greater emphasis on identifying high-need patients for care management, integrating behavioral health screenings and treatment into primary care practice, and engaging patients in their own care. The 2014 Level 3 designation is expected to yield NYC Health + Hospitals approximately $60 million in state reimbursements over fiscal years 2018 and 2019.

“Making high-quality primary care more accessible for our patients is a linchpin of our health system transformation efforts,” said NYC Health + Hospitals Interim President and CEO Stanley Brezenoff. “Meeting these tough national standards for primary care services underscores the commitment to excellence from our clinicians, administrators, and staff and our ability to seize the opportunity to maximize payment incentives to ensure financial sustainability.”

The National Committee for Quality Assurance’s PCMH designation is granted to primary care practices that have implemented a delivery model of care that ensures access, communication, and shared responsibility among a cross section of providers, including doctors, nurses, and social workers, who must work together to improve patient health outcomes.

NYC Health + Hospitals primary care teams have implemented the following strategies to earn the PCMH 2014 Level 3 designation:

Expanding Access through Televisits – By providing the same level of care as an office visit, televisits allow physicians and patients to communicate over the phone between in-person appointments and discuss any changes to the patient’s health. Televisits may be used, for example, as follow-up visits where primary care physicians can assess and modify a diabetic patient’s plan of care based on recent test results. NYC Health + Hospitals conducted more than 2,200 televisits between December 2016 and June 2017.

Targeting High-Need – To meet new requirements on care management, most NYC Health + Hospitals primary care teams focused on patients who recorded higher costs or utilization, demonstrated a need for social services, and exhibited poorly controlled chronic conditions, such as hypertension and diabetes.

Integrating Depression Screening in Primary Care – NYC Health + Hospitals developed a collaborative care model that better identifies and treats depression in the primary care setting and aligns with PCMH goals for behavioral health integration. Primary care practices also enhanced engagement with patients by incorporating patient education materials into the electronic health record.

Conducting Daily Huddles – Among the workflow improvements related to PCMH recognition, care teams gather for a daily huddle to go over potential challenges for the day and discuss complex patients who may require additional time. The huddles include the entire care team—from clerical staff to provider—to ensure everyone is up to speed on any issues affecting the team.

Developing Care Plans for All Patients – Care plans remind patients of their goals and allow patients to share the information more easily with families and friends, which is particularly important for patients who need family caregiver support for a chronic disease, such as diabetes or hypertension.

“Many patients face various obstacles that make it difficult for them to regularly travel and have face-to-face visits with their providers. Now we are able to build a relationship because televisits allow us to connect easily,” said Marisa Lam, MSN, RN-BC, AGNP-C, AGPCNP-BC, NYC Health + Hospitals/Gotham Health, Gouverneur. “I have one patient who works six days a week and has difficulty getting time off for appointments, but he scheduled a televisit during his lunch break to discuss his health. This is truly a patient-centered approach.”

PCMH Reimbursement

The New York State Department of Health provides incentive payments for certain patient populations, including patients enrolled in Medicaid managed care and Medicaid fee-for-service. Historically, incentives tied to 2014 standards were as much as double those tied to 2011 standards. For example, in January 2016, a recognized Medical Home received a bonus payment of $4 per Medicaid managed care member per month, whereas the same patient under the 2014 standards generates $7.50 monthly. New York State continues to promote the higher 2014 standards by discontinuing all enhanced payments related to 2011 standards for both fee-for-service and managed care patients, as of July 2017.

Helping Community Providers Achieve PCMH Designation

“Our experience in achieving PCMH recognition also builds a necessary foundation for other system-wide transformation initiatives,” said Dr. Dave Chokshi, Chief Population Health Officer at OneCity Health, a subsidiary of NYC Health + Hospitals focused on population health, care management, and implementation of the State’s Delivery System Reform Incentive Payment (DSRIP) program. “Through OneCity Health, we are currently assisting 36 community-based partners representing over 100 additional primary care sites in our Performing Provider System to establish this patient-centered model, which strengthens their role as partners in care and also allows them to receive higher reimbursements.”

“Two of the core tenets of DSRIP are to reduce hospital use and to promote linkages to primary care,” said Jen Lau, Senior Director, Primary Care Transformation, OneCity Health. “With PCMH recognition, we know that both NYC Health + Hospitals primary care clinics and those in our partner network are equipped with the tools and resources to provide high-quality primary care, particularly when patients transition from an Emergency Department visit or a hospital admission.”

NYC Health + Hospitals PCMH Level 3 primary care practices, by borough:


NYC Health + Hospitals/Jacobi
NYC Health + Hospitals/Lincoln
NYC Health + Hospitals/North Central Bronx
NYC Health + Hospitals/Gotham Health, Belvis
NYC Health + Hospitals/Gotham Health, Morrisania
NYC Health + Hospitals/Gotham Health centers in Williamsbridge and Tremont


NYC Health + Hospitals/Coney Island
NYC Health + Hospitals/Kings County
NYC Health + Hospitals/Woodhull
NYC Health + Hospitals/Gotham Health, Cumberland
NYC Health + Hospitals/Gotham Health, East New York
NYC Health + Hospitals/Gotham Health centers in Brownsville, Bushwick, Fort Greene, Greenpoint, and Williamsburg (3)


NYC Health + Hospitals/Bellevue
NYC Health + Hospitals/Harlem
NYC Health + Hospitals/Metropolitan
NYC Health + Hospitals/Gotham Health, Gouverneur
NYC Health + Hospitals/Gotham Health, Sydenham
NYC Health + Hospitals/Gotham Health, Roberto Clemente
NYC Health + Hospitals/Gotham Health centers in Inwood and Harlem


NYC Health + Hospitals/Elmhurst
NYC Health + Hospitals/Queens
NYC Health + Hospitals/Gotham Health centers in Jamaica, South Jamaica, and Springfield Garden