Health Department, United Hospital Fund, and Partners Release Plan Outlining Strategies to Increase Broad Adoption of Primary Care Medical Home Model to Promote Health Equity

The New York City Department of Health and Mental Hygiene, United Hospital Fund (UHF), and partners in the Population Health Improvement Program (PHIP) today released a plan that outlines five strategies to expand and improve the impact of the medical home model of primary care across New York City. The plan is intended to guide New York City's primary care providers, as well as health plans, policymakers, and other stakeholders, in the adoption of a delivery model that improves health care quality, improves patients' experience of care, and reduces avoidable emergency department visits and hospital admissions.

Expanding the adoption of the medical home model has been a central and unifying theme across New York State's signature health reform initiatives, including the State Health Innovation Plan (SHIP), and is a promising approach for supporting New York City's Take Care New York 2020 (TCNY 2020) goals. A strong primary care system is essential to addressing health inequities and improving the health of New York City's residents, especially in communities that face high health disparities. The plan can be found on the department's website at

“This plan underscores the widely accepted understanding that strengthening primary care is essential to improving the health of our communities,” said Health Commissioner Dr. Mary T. Bassett. “The plan's aim is to prevent premature deaths, which occur disproportionately among Black and Latino residents of New York City. More effective primary care is a key part of ensuring that lives are not cut short for preventable causes.”

“This plan is the culmination of work by some of our city's most knowledgeable health care providers, insurers, consumers, policymakers, and other stakeholders, all of whom are committed to improving the health of our communities through enhanced primary care,” said First Deputy Health Commissioner Dr. Oxiris Barbot. “These experts share in our commitment to creating greater health equity in our city.”

“The medical home has proven to be an effective model to improve primary care and outcomes for patients, and improving primary care is at the core of virtually every plan to reform health care more broadly,” said Jim Tallon, president of United Hospital Fund. “New York State already leads the nation in the adoption of this model, and the commitment by the City to achieve its adoption by 80 percent of primary care providers by 2020 is an exciting next step.”

"These strategies underscore the Department of Health's commitment to bringing innovation to our healthcare system, so that more New Yorkers can receive the primary care that they deserve," said Council Member Corey Johnson, Chair of the Committee on Health. "If we are to meet our City and our State's ambitious goals to improve community health and expand access to everyone, it will take measures like the adoption of the medical home model. I'm grateful for the strong leadership of Commissioner Dr. Mary Bassett, our outstanding Department of Health, and their partners at the United Hospital Fund the Population Health Improvement Program."

A medical home features expanded access to care, a team-based approach to providing care that is responsive to patient needs, coordination of care during care transitions, improved connections to community-based resources, and the use of quality improvement tools to measure and report outcomes.

The new plan advocates for a zone approach – a new methodology grouping the city into zones (A through C) in order to prioritize medical home adoption in communities with the greatest disease burden.

A broad, multi-stakeholder group of New York City-based health care leaders, practitioners, and advocates identified five essential considerations for ensuring all New York City residents can access high-quality primary care via medical homes:

Prioritize medical home adoption in communities with the greatest health inequities
Ensure medical home adoption is accessible and sustainable for small practices
Support the integration of behavioral health care as part of the medical home
Coordinate various medical home initiatives underway across New York State
Achieve multi-payer support to sustain the medical home model
Expanding the medical home model and improving the performance of the state's primary care system has been a central and unifying theme across New York State's signature health reform initiatives and is a promising approach for supporting New York City's TCNY 2020 goals. Research has consistently shown a relationship between robust primary care and reduced infant mortality, reduced premature mortality, and better self-reported health status – all three of which are lead indicators for TCNY 2020.

This report was informed and guided by a diverse group of primarily New York City-based health care leaders, practitioners, and advocates. Over the course of nine months, they came together as the New York City Advanced Primary Care Planning Group to advise on the development of an action plan for improving New York's primary care system. Additional input came from five consumer focus groups conducted by the New York Academy of Medicine between November 2015 and January 2016. Together, they led to the creation of the five-point agenda.

Organizations that were represented on the New York City Advanced Primary Care Planning Group include: Albert Einstein College of Medicine, The Children's Hospital at Montefiore, The Commonwealth Fund, Community Health Care Association of New York State, Community Healthcare Network, Emblem Health, Empire Blue Cross Blue Shield, Greater New York Hospital Association, HANYS Benefit Services, Hartford Institute of Geriatric Nursing at NYU, Healthcare Association of New York State, HealthFirst, Institute for Family Health, IPRO, Maimonides Medical Center, Medicare Rights Center, Metro New York Health Care for All Campaign, MetroPlus Health Plan, Montefiore Care Management Company, the New York Chapter of the American College of Physicians, New York City Health + Hospitals, New York-Presbyterian Hospital, Northeast Business Group on Health, NYC Department of Health and Mental Hygiene, NYS Academy of Family Physicians, Primary Care Development Corporation, Staten Island Performing Provider System, and Weill Cornell Medical College.

Population Health Improvement Program

In January 2015, the Fund for Public Health in New York joined in partnership with the New York City Department of Health and Mental Hygiene, United Hospital Fund, and The New York Academy of Medicine to launch the New York City Population Health Improvement Program (PHIP). The NYC PHIP is one of 11 PHIPs created around the state, with funding from the State Department of Health, working to achieve inclusive health planning at the regional and local level. The PHIP will promote health equity for New Yorkers, as well as the “Triple Aim” of better care, lower health care costs, and better health outcomes.

A Strategy for Expanding and Improving the Impact of the Medical Home Across New York City is also available here

About United Hospital Fund: United Hospital Fund works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care.

Aug. 25, 2016
Focus Area
Clinical-Community PartnershipsQuality and EfficiencyCoverage and Access
Innovation Strategies