* Please note: This project is no longer active. The resources and information below are provided for archival purposes and may be out of date. Contact info@uhfnyc.org if you have any questions or concerns.

Supported by a contract from the New York State Department of Health (Health Research Incorporated)

Rising and unsustainable health care expenditures demand new approaches to organizing and paying for care, especially for those with chronic conditions. In response, initiatives by government, payers, and provider organizations are converging to transform the delivery of primary care and a new model is taking root: the patient-centered medical home (PCMH).

Why This Is Important

This more holistic, comprehensive, and coordinated model represents a shift from away the standard encounter-based office visit. And there is some early evidence that it is yielding reductions in avoidable hospitalizations and emergency visits, as well as associated cost savings.

Our Work

A major initiative, led by the New York State Department of Health (NYSDOH) with funding support through a State Innovation Models award from CMS, has supported the refinement and spread of New York’s PCMH model, now known as NYS PCMH. UHF has assisted NYSDOH’s initiative in several ways:

  • Contributing to the design of the NYS PCMH model including strategies for integrating behavioral health, defining high-quality primary care, and supporting small practices
  • Helping to build capacity to measure, monitor, and improve quality with new tools, including a Core Measure Set and scorecards for assessing performance by primary care practices
  • Engaging stakeholders in an annual stewardship process for updating and maintaining the Core Measure Set to ensure it is informed by advances in measurement science and minimizes reporting burdens
  • Convening two multi-stakeholder workgroups to help strengthen NYSDOH’s transparency efforts through more meaningful and user-friendly profiles of provider quality that could inform New Yorkers’ decisions about where to seek care
  • Participating in convenings of regional stakeholders to help spread practice transformation, align quality reporting, and advance value-based payment models

The Bottom Line

Enormous progress in primary care transformation has been achieved in New York, but challenges remain: a confusing array of payment models and provider contracts for clinicians to navigate; lack of support to sustain the costs of practice transformation, including health information technology costs; a shortage of primary care clinicians in rural areas; and the rising popularity of competing models like retail clinics, urgent care, and telemedicine. Maintaining momentum will likely require more investment and engagement and evidence of better outcomes, lower costs, and patient and clinician satisfaction.


NYS Primary Care Core Measure Set, 2020

Patient-Centered Medical Homes in New York, 2018 Update: Drivers of Growth and Challenges for the Future

Advanced Primary Care Quality Improvement Resource Compendium I and Compendium II

Process for Developing a Core Measure Set to Assess Quality and Value of Primary Care in New York State (poster)