Practice Transformation

Advanced Primary Care

What is Advanced Primary Care?

The Advanced Primary Care (APC) model is designed to help practices succeed in value-based payment (VBP) models being developed by both public and private payers. Practices working on APC will develop and optimize capabilities for discussing and collecting advanced directives, stratifying patients by health risks, developing care plans collaboratively with patients, engaging patients via the patient portal, and much more. APC builds on PCMH principles and includes multi-payer financial support.

Practices participating in Advanced Primary Care can receive up to 2 years of free technical assistance support from NYC REACH. Technical assistance for APC support is available until March 2019.

All practice sites that provide primary care are eligible to participate in Advanced Primary Care. This includes pediatrics, internal medicine, and family medicine.

A practice is eligible for support as long as the practice is not concurrently receiving any other federally funded transformation technical assistance (e.g.: TCPI, DSRIP-supported PCMH).

Free Technical Assistance
Technical assistance from NYC REACH includes:

  • Customized practice assistance, consisting of tools, guides, and coaching
  • Remote and on-site support from NYC REACH practice transformation experts
  • Opportunities to attend trainings and learning collaboratives

Financial Incentives

Upon beginning the practice transformation process, practices will be assessed to determine what gate they enter into for APC. Participating practices will then receive multi-payer incentives by advancing through the APC gates.

APC Website Table

Advanced Primary Care Alignment

Medicare Access and CHIP Reauthorization Act (MACRA)
Achieving Advanced Primary Care better aligns practices for the Merit-based Incentive Payment Systems (MIPS) portion of MACRA.
Patient-Centered Medical Home (PCMH)
Practices who are recognized as a PCMH Level 3 will enter APC at a higher gate, positioning them for more incentive money.
Regional Health Information Organization (RHIO)
Connection to a RHIO is a requirement for later gates in APC. Incentive money is currently available to eligible practices for RHIO connection.

To receive FREE APC Practice Transformation support, email: apc@health.nyc.gov

To ask questions pertaining to APC Practice Transformation, join FREE Office Hours, which are held on the last Tuesday of every month from 2:30-3:30.

Patient-Centered Medical Home

What is PCMH?
A Patient-Centered Medical Home (PCMH) is a model for primary care practices that emphasizes care coordination and communication. This patient-centric approach ensures that each patient is assigned a physician within a practice whom the patient can see consistently. Utilizing this model, practices have the capability to give their patients increased access to their physicians.

PCMH achieves the “Triple Aim” and is a fundamental part of the New York State Health Innovation Plan and Medicaid’s Delivery System Reform Incentive Payment (DSRIP) Program. Triple Aim is a framework that strives to simultaneously pursue three dimensions: improve the patient experience of care, improve the health of populations, and reduce the per capita cost of health care. PCMH offers a framework that helps practices become ready for 21st century health care by ensuring that processes are in place for care coordination, care management, and quality improvement.

A practice that achieves PCMH recognition receives enhanced reimbursement from New York State Medicaid. In addition, PCMH-recognized practices will also see an improvement with care coordination, patient engagement, and health outcomes.

NYC REACH has assisted over 700 practices to achieve PCMH recognition.

The video above highlights the framework of the Patient-Centered Medical Home.
How can a practice become a PCMH?
Transform your practice using the Standards and Guidelines set by the National Committee for Quality Assurance (NCQA) and achieve recognition.

The NCQA PCMH program’s six standards align with the core components of primary care:

PCMH Standards Overview

Source: Emmi Solutions, LLC

Why should a practice become a Medical Home?
By becoming a Medical Home, a practice will:

  • Improve care coordination, patient engagement, and health outcomes
  • Establish efficient workflows for clinic operations.
  • Receive enhanced reimbursement from NYS Medicaid:
PCMH New Payment Table

How Can NYC REACH Help?

NYC REACH offers a range of PCMH services established by the National Committee for Quality Assurance (NCQA) to assist with PCMH transformation. NCQA PCMH recognition is the most widely adopted model for transforming primary care practices into medical homes. NYC REACH has worked with hundreds of practices and offers services such as coaching, gap analysis, and documentation review. For questions regarding any services, contact PCMH@health.nyc.gov.
PCMH Services Provided by NYC REACH

Group Training

Held monthly, the full-day in-person group training focuses on a review of the NCQA Standards and Guidelines and advises practices with their preparation, documentation, and submission process. The group training is a first step for practices interested in PCMH transformation. Click here for more information and to RSVP for an upcoming group training.


NYC REACH also offers customized training for large organizations, ACOs, and IPAs, to meet goals set by member practices. This organizational-based training can include “train-the-trainer” sessions wherein NYC REACH staff will coach others to then deliver PCMH training. For more information and to set up a training session for your practice, e-mail PCMH@health.nyc.gov.

Documentation Review

NYC REACH will audit and review all prepared application materials and documentation prior to submission to the NCQA and provide a detailed summary report of the audit.

Gap Analysis

NYC REACH will conduct an assessment of a practice’s workflow and utilization of health information technology. This assessment will help provide an understanding of a practice’s progress in regards to PCMH recognition. This includes an interview with key staff and an on-site visit, as well as a written report with recommended next steps.

Coaching and Transformation

NYC REACH offers coaching and assistance to aid practices with project management support and technical assistance to enhance workflows, EHR setup, and practice team capabilities to meet PCMH Standards and initiate the PCMH recognition process.

Free Office Hours

NYC REACH hosts free monthly online office hours for NYC REACH members. Participants have the opportunity to ask questions on topics such as PCMH standards, guidelines, and documentation processes.

Delivery System Reform Incentive Payment/Performing Provider Systems Services

NYC REACH assists DSRIP PPSs with readying associated primary care practices to achieve NCQA PCMH Level 3 recognition. Partnering with PPS leads, NYC REACH aligns PCMH implementation objectives with selected DSRIP projects, collaborates with PPS stakeholders on practice transformation strategy, and develops customized work plans to best meet the specific cultural and geographic needs of PPS practices.

How Can I Learn More About PCMH?

PCMH Resources
The following links provide great foundational information that will help practices learn more about PCMH and practice transformation:

PCMH Group Training Testimonials

Transforming Clinical Practice Initiative

What is the Transforming Clinical Practice Initiative?

The Transforming Clinical Practice Initiative (TCPI) is a Centers for Medicare and Medicaid Services (CMS) funded program that aims to help clinicians make the clinical and business changes needed to thrive in the new healthcare environment and prepare for new payment models. TCPI participants are grouped into Practice Transformation Networks (PTNs), which are peer-based learning networks designed to allow clinicians be actively engaged in the practice transformation process. NYC REACH members can join the New York State Practice Transformation Network (NYS PTN) and receive technical assistance services from NYC REACH at no cost to the practice.
The Transforming Clinical Practice Initiative is open to primary and specialty care providers within a Practice Transformation Network (PTN). Enrollment is open to:

  • MDs, DOs, PAs, NPs, Clinical Nurse Specialists, Clinical Psychologists, LCSWs
  • Providers using a 2014 certified EHR
  • Providers not currently participating in a Medicare Share Savings Program, Pioneer ACO Program, Multi-Payer Advanced Primary Care Program, or Comprehensive Primary Care Initiative
Free Technical Assistance
NYC REACH will work with practices until they are ready to graduate from the TCPI program.

Technical assistance from NYC REACH includes:

  • Transformation support through a combination of remote and on-site training
  • Trainings and peer information sharing opportunities during collaborative events
  • Access to national expert faculty and resources

TCPI Benefits for Clinicians

Doctor Image

Practice Transformation Networks

NYC REACH supports two Practice Transformation Networks: the New York State Practice Transformation Networks and the Greater New York City Practice Transformation Network (a group led by NYU School of Medicine).
TCPi Logo 1

Learn More about TCPI

Healthcare Communities: The official TCPI website that disseminates key information and notifications.

Incentives for RHIO Connectivity: Joining a Regional Health Information Organization can help a practice succeed in TCPI and new payment models. Incentive money is currently available to eligible practices for RHIO connection.


For more information about the Transforming Clinical Practice Initiative, please contact Janice Magno at jmagno@health.nyc.gov.

Connect to a RHIO to Succeed in Practice Transformation

What is a Regional Health Information Organization?

A Regional Health Information Organization (RHIO) is a public Health Information Exchange (HIE). RHIOs receive patient data from the EHRs of various organizations, such as: small practices, hospitals, behavioral health organizations, community based organizations and major health systems. Members of a RHIO are able to access information about their patients that is shared by other providers within their RHIO. They can also access information from the Statewide Health Information Network of New York (SHIN-NY). The RHIOs serving the New York City area are:

 Receive notifications when your patients visit the Emergency Department.
See discharge summaries without going through hospital medical records.
Obtain consult notes without reaching out to the specialist office.

Program Alignment

RHIO connectivity can help practices be successful in current transformation projects, such as:

Advanced Primary Care

Patient-Centered Medical Home

Transforming Clinical Practice Initiative

How do Practices Pay for RHIO Connectivity?

Financial Incentives:
The New York State Department of Health is offering incentive money to help defray the costs of connecting to a RHIO. Money is available until September 2017. Funding is awarded on a first-come first-serve basis.

Incentive Eligibility Requirements

  • MD, DO, Dentist, NP, CNMW, PA, or Behavioral Health provider practicing in a FQHC, Article 28 Nursing Home or DTC, Article 36 Certified Home Health Care Agency or Long Term Home Health Care Program, or Hospice facility

  • Organization has an ONC certified EHR that is able to submit data to the RHIO as CCD or C-CDA

  • Organization accepts Medicaid in one of the following forms: Fee-for-Service, Managed Care, or HARP

  • Successful attestation for AIU (Adopt/Implement/Upgrade) of the Medicaid EHR Incentive Program

For more information about the RHIO incentive program, please contact Via Abolencia at vabolencia@health.nyc.gov