October 31, 2017
Based on feedback from our partners, BHA will now produce newsletters every quarter to highlight key information and share updates on our progress.

Breathe Better Bronx - Success Story 
Breathe Better Bronx (BBB) is the asthma program developed by BHA PPS.  The program's goal is to help people in the South Bronx control their asthma through asthma treatments, home-based services, medication management, and education.  Active partners include Bronx Lebanon Hospital Center, BronxWorks, Urban Health Plan, and Boom! Pharmacy. Since the beginning, the BBB team has counseled over 400 adult and pediatric patients with the goal of reducing incidences of asthma attacks, visits to the ED, and Inpatient stays. 
Here is just one example of how BBB has impacted one family in our community:
In January of 2017 the Breathe Better Bronx (BBB) Community Health Worker(CHW) team was alerted by Care Transitions Nurse that there was a patient admitted to the inpatient pediatric floor for asthma.  She recommended that the patient and her family meet with the BBB team to discuss her asthma needs. The BBB CHW met with the family and provided asthma education bedside.  He told them about the BBB services such as a home assessment and additional asthma education. Several weeks later the patient and her family attended a workshop at the BBB offices to learn more about the disease and ways to manage medications and understand the impact of the triggers. At the workshop the family was referred to BronxWorks for a home assessment.  The family identified that the home could be a trigger because of roaches, mold and chipping paint. Through advocacy efforts with the landlord, education about asthma and the home environment, and tangible remediations such as mattress protectors, green cleaning supplies and Swiffer duster, the patient reported that the asthma was now well managed. The BronxWorks team successfully advocated for the landlord to make repairs to the home such as scraping peeling paint and applying roach gel to the cabinetry.  There have been no Emergency Department visits or hospital inpatient admissions since January when our team started working with them.
NYSDOHMH "Partnering to Achieve Health Equity" Webinar series:
NYS Department of Health and Mental Hygiene is sponsoring a webinar series created for partners in hospitals and Performing Provider Systems who are informing or making decisions on community health planning. The goal is to share information on various health topics and also improve awareness of related resources offered at DOH.  Upcoming topics include Birth Equity, Behavioral Health Peer Specialists, and Health Equity for LGBT New Yorkers. 

To register and view upcoming events, please contact Asia Young at ayoung6@health.nyc.gov

PCMH Update
As of September 2017, 225 PCPs (Primary Care Providers) in our network were certified PCMH 2014 Level 3.  At this point, our vendor Insight Management continues (they continue - OMIT) to work closely with remaining sites/providers that have needed extra attention in order to make the jump from paper to an EHR (Electronic Health Record) as well as those who are just beginning the journey to PCMH Certification.  
StakeholderCommittee Update 
BHA PPS Evening Town Hall - November 30, 2017
BHA PPS's last Town Hall for 2017 will be an evening of networking and learning on Thursday November 30, 2017, from 4-8 pm, at the Bronx Museum of the Arts. In addition to sharing updates on DSRIP initiatives, the focus of this Town Hall will be Health Homes. 

Leadership from Bronx Lebanon Health Home, Community Care Management Partners (CCMP) Health Home, and Collaborative For Children and Families (CCF) Health Home will share information about Health Homes goals, target communities, and referrals.  As a result of this Town Hall, BHA PPS seeks to educate and link PPS Primary Care Providers, social service, and community based organizations, as well as Federally Qualified Health Centers, hospitals, nursing homes, and behavioral health providers to Health Homes Resources.

To register for this Town Hall, please click here  

Primary Care Webinar Series
BHA PPS is committed to making sure all of our primary care providers and care teams, both hospital-based and community-based, have access to training to support them in working with patients with various conditions.  The Stakeholder PCP champions have partnered with the Workforce Committee to launch a webinar series to increase knowledge, skills, and understanding of the most pressing issues in our target communities.  

The first webinar was held September 20th focused on "Behavioral Health and Primary Care Integration".  The one-hour session was led by Virna Little, PsyD, LCSW-r, MBA, SAP, CCM, Senior Vice President of Psychosocial Services and Community Affairs at the Institute for Family Health in New York and Dr. Eric Gayle, a family medicine doctor in Bronx, New York with over 20 years or practice experience. The discussion focused on the rationale and challenges to integration of Primary Care and Behavioral Health.  The presenters discussed the IMPACT model, lessons learned from their years of experience and also a few patient success stories.  The webinar has been recorded and posted on HWApps.  Those that view the event, if eligible, can receive 1 CME for MDs or 1 CEU for Social Workers.

Future proposed topics include:
  •  Increasing Medication Adherence
  •   Health Literacy and its Impact on Primary Care
  •   Asthma Disease Management (Peds and adults)
Please be sure to join our mailing list at info@bronxhealthaccess.org to ensure you receive announcements for upcoming webinars.  

Project Updates
As of DY2Q4, the Health Home at Risk project has completed 71% of project milestones. 
DY3 welcomed a number of new contracted partners to the Health Home at Risk project.  In order to locate patients with "rising risk" (1 chronic condition and at risk for development of a 2nd condition), the project has implemented a model where embedded care coordinators will identify, engage, enroll, and support patients in meeting health outcomes, as identified by their primary care team. 
We look forward to sharing further outcomes of this vital work in population management and are proud to partner with the following agencies in our network:
-          Boom! Health
-          Brightpoint Health
-          Bronx Lebanon Hospital Center
-          Dennelisse Corporation
-          Hudson Heights IPA
-          Unique People Services
-          Urban Health Plan
-          VIP Community Services
A vendor agreement with expectations for targeted patient caseload/care coordination services has been signed. Ongoing monthly meetings are held with our 7 partners to share best practices.
Collaboration with BHA Cardiology department has allowed us to embed a CHW as of July.
An "Action list" in the Electronic Medical Record (EMR) at BLHC was implemented to identify eligible patients for HH@R.  This will enable CHWs and care team members to proactively outreach to eligible patients.
2.b.i - Ambulatory Intensive Care Unit
As of DY2Q4, the Diabetes project has completed 71% of project milestones. 
At BLHC, AICU has been implemented at two primary care sites: Bronxcare at 3rd Avenue and Health and Wellness Center. A weekly, hour-long, multidisciplinary case conference is held at each of these sites, devoted to discussion and treatment planning for patients needing care enhancement. Approximately 5 cases are presented at each site per week, including new patients and follow-up from previous cases. Any staff member attending the meeting can bring up a case or contribute to the discussion. The Care Transitions program provides a weekly list of clinic patients who have been hospitalized or see in the ED, and HealthFirst provides a list of their members who have been identified as high utilizers. Both of these lists aid the clinical staff in case selection for AICU.  The aim of the case conference is to ensure the patient receives needed services, including medical, specialty, behavioral health, social and support services.
3ai - Behavioral Health
As of DY2Q4, the Behavioral Health project has completed 40% of project milestones.
At BLHC, IMPACT has been clinically implemented at two clinics and are beginning to track patients. Spread to a third clinic has launched. VIP and Uptown Healthcare Management continue to partner with consultants to set the foundation for IMPACT implementation.
3ci - Diabetes
As of DY2Q4, the Diabetes project has completed 71% of project milestones. 
As a means of reducing short-term complications, BLHC will pilot group visits and shared medical appointments. Research has found that these strategies have led to improved outcomes for patients with diabetes.
3dii - Asthma
As of DY2Q4, the Asthma project has completed 75% of project milestones. 
The workgroup continues to meet regularly to identify successes, challenges, and continuously improve services implemented to our community.
The workgroup recently approved a flier to be distributed to partners  interested in referring eligible patients.  Patients would be enrolled into Breathe Better Bronx, a no-cost program that helps people in the South Bronx control their asthma through asthma treatments, home-based services, and education.  Breathe Better Bronx Asthma Care Team members offer support services for managing asthma in adults and children.  These include:
  • Phone calls from an Asthma Care Team member to monitor symptoms and schedule medical appointments
  • Up to 3 home visits per year to find and get rid of asthma triggers
  • Finding pharmacies that take client's insurance
  • Education about medication
To refer a patient to Breathe Better Bronx, please contact :
Certified Asthma Educator (Eng, Spa) 347-558-5471
Community Health Worker (Eng) 347-268-4449

3fi - Maternal Child Health
As of DY2Q4, 100% of project milestones have been completed for the Maternal and Child Health project.  

Partners that are interested in referring pregnant or parenting mothers with children up to 20 months old can contact Glenys Perales-Thomas, MCHES, Program Director at (718) 960-1373.  Prevention services include:
  • Prevention Education (ex. Nutrition, Prenatal Care, Labor Preparation, Post Partum Care, Breastfeeding)
  • Scheduling Appointments for Mom and Baby
  • WIC Referrals & Appointments
  • Transportation Assistance
4cii - HIV
  • The HIV project workgroup continues to work on developing the peer workforce and establishing a case to the State for a billable rate for peer services.  They have partnered with The Alliance for positive change to conduct a peer certification training program.  13 participants completed Phase 1 - Foundational Training on September 8th.  10 of them continued on to Phase 2 - Certification Training along with an additional 13 new enrollees.  A graduation ceremony will take place at 12pm on Thursday, November 9th in the downstairs auditorium at 199 Mt. Eden Parkway for all who successfully complete the program.  They will then be eligible to sit for the NYS AIDS Institute Peer Certification exam.
  • In addition to the classroom training, which takes places in 3 full days per week over 6 weeks, the Alliance also provides group support meetings and 1-on-1 support sessions for peers.
  • The workgroup partners are currently working on developing a list of identifiers to submit to Steve Maggio in order to begin tracking peer interventions.  So far 1 partner has submitted a list to him and others except to follow in the next 2 weeks.  This is a part of the long term sustainability plan to show the effectiveness of peer interventions.
4aiii - 100 Schools project
Behavioral Health Coaches are actively working in over 40 schools throughout New York City.  Of these, 9 schools are located in the Bronx.  All Behavioral Health Teams are now fully staffed, hiring is under way for Phase 3 coaches
An additional 58 schools have been identified for project implementation in Fall 2017.  Each of these Phase 3 schools have been notified and orientation meetings have been held with staff included school principals, guidance counselors, etc. These meetings have provided an introduction to the project and DOE and OSH administration have joined in the presentation to show support and endorsement of the project.  Based on experiences with schools that are already involved in the 100 Schools Project, a library of presentations has been created for coaches to offer to school staff; additional trainings are being developed to match needs identified in the school plans.
For reporting purposes, coaches will be tracking their efforts and referrals using Healthify.  Contracting with Healthify has been completed and staff training for Jewish Board and NYAM has been completed and trainings for coaches and supervisors are being scheduled for July and August.  Healthify will be introduced to first 8 schools in Brooklyn that are open for the summer in early August. 

For any questions regarding the content of this email, please feel free to reach out to Editor of the Bronx Health Access Newsletter, Felix Delgado (Stakeholder Engagement Manager) at Fdelgado@bronxleb.org


For more information about Bronx Health Access PPS, please send an email to info@blhcpps.org 


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