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The Big Picture

BPHC believes that getting the care right means integrating our healthcare delivery system: coordinating a range of healthcare and social services so that patients receive the right care when they need it. Our strategy for realizing this vision relies on a strong foundation in primary care and well-coordinated community-based services.

Transformation Rooted in Primary Care

Primary care is where patient wellness begins. It is where doctors identify health risks early and connect patients to the care they need; it is where patients learn to manage their own health; and it is the most powerful tool we have to manage chronic conditions and prevent unnecessary hospitalizations. For this reason, we are making sure that every primary care practice in our PPS has the opportunity to become a medical home at the highest level and achieves NCQA recognition as a Level 3 Patient Centered Medical Home (PCMH).

PCMH is a model of primary care delivery dedicated to the “Triple Aim”: improved population health, better patient experience (which includes higher quality of care), and lower per capita cost of healthcare. But what does this look like in action?

The first step in achieving PCMH recognition is increasing patient access, often by scheduling same-day appointments and allowing 24/7 access to providers. Once the patient is in the door, they are seen by their care team. The care team treats and tracks a panel of patients, coordinates necessary services (including behavioral health and community services), and follows up with patients after every visit.

The journey to PCMH recognition is hard work. “Trying to do it from the beginning is tough,” says Denise Nuñez, the Medical Director at Divino Niño, a small pediatric practice with PCMH Level 3 recognition. “You need people, you need resources, and you need money,” But for her, it was worth the investment. “Quality, efficiency, and professionalism. PCMH has had a huge impact,” she says.

In other words PCMH works, and our PPS is working to achieve it at the highest level possible. We understand that establishing an NCQA-recognized medical home may require difficult changes in practice and workflow, which is why we have recruited PCMH coaches to provide guidance and support with the PCMH application and the practice transformation that will follow.

Image of Denise Nunez
Denise Nuñez is the Medical Director at Divino Niño Pediatrics and pediatrician specializing in critical care.

Integration of Community Services in Healthcare Delivery

Picture a child who puffs on an inhaler in a moldy bedroom; a woman for whom a hospital bed is the alternative to sleeping on the street; a man who cannot read the instructions for his diabetes medication. There are countless Bronx residents who must overcome social, economic, and cultural challenges simply to stay healthy.

Community-based organizations are vital members of our PPS because they address these challenges. They complement the work of healthcare providers, connecting patients to the care they need and helping patients stay healthy when they leave the doctor’s office. BPHC will focus on coordinating and integrating community-based social services into the healthcare delivery system, so that they work in tandem with clinical care to treat the whole patient.