Practice Transformation

Advanced Primary Care

What is Advanced Primary Care?

New York State Department of Health is launching Advanced Primary Care (APC) because healthcare billing and reimbursement will change dramatically in New York State over the next few years. By 2020, 80% of primary care will be paid for under a value-based arrangement. Insurance companies, including Medicaid and Medicare, will base payments to providers on the quality of care a provider delivers to their patients. For a provider to meet these new and higher standards of care as well as to manage and report their quality accurately to payers, providers will need to change practice workflows, operations, and use of health information technology.

APC builds on principles established by Meaningful Use and Patient-Centered Medical Home to also include multi-payer financial support. Practices committed to APC will enhance their abilities for identifying patients by health risks; developing care plans cooperatively with patients; and electronically engaging with patients via the patient portal.

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

APC services are provided at the site-level. Practices with sites that provide primary care services such as pediatrics, internal medicine, and family medicine are eligible to participate in Advanced Primary Care.

A practice is eligible to participate in APC if they are not concurrently receiving federally-funded transformation technical assistance (e.g. TCPI, DSRIP-supported PCMH). NYC REACH can determine if a practice meets these eligibility requirements.

Free Technical Assistance
Technical assistance from NYC REACH includes:

  • Training and guidance on implementing workflow changes
  • Education on new and existing state and federal payment reform programs, such as the Quality Payment Program (QPP) and Patient-Centered Medical Home (PCMH)
  • Customized practice assistance, tools, and coaching
  • Remote and on-site support from practice transformation experts
  • Peer networking opportunities through trainings and collaborative events

For practices interested in participating in APC and receiving free technical assistance from NYC REACH must complete a self-assessment.

Please click here to access the APC self-assessment tool.

Financial Incentives
Practices will receive outcomes-based incentive payments from multiple payers as they achieve APC benchmarks.

APC programmatic benchmarks consist of making a commitment to the program, demonstrating readiness for care coordination, and demonstrated APC capabilities through outcomes.

Participation in APC will support a practice’s progression through additional incentive-based federal and state programs:

Medicaid EHR Incentive Program – Achieving Meaningful Use establishes a foundation that will lead to successes in MIPS, PCMH, and APC.

Patient-Centered Medical Home (PCMH) – Practices that receive Level 3 PCMH recognition are able to enter APC at a higher threshold, which can result in higher incentive payments.

Merit-Based Incentive Payment System (MIPS) – APC prepares practices for the MIPS portion of the Medicare Access and CHIP Reauthorization Act (MACRA).

Regional Health Information Organization (RHIO) – Connection to a RHIO is a requirement for advancing in APC. Funding for RHIO connectivity is currently available from the New York State Department of Health.

For questions about APC: contact apc@health.nyc.gov or join NYC REACH’s free Office Hours on the last Tuesday of every month starting at 2:30 p.m.

Click here to access the Office Hours: http://bit.ly/PTOfficeHours and use the password “Nycreach1”

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:
Effective July 1, 2017, the revised reimbursement amounts will be as follows:
Updated PCMH Graphic (Website)
Please note: Incentive payments will no longer be available for NCQA’s 2011 standards after July 1, 2017.

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) helps clinicians thrive in the advancing healthcare environment by supporting changes to clinical and business practices for participation in new payment models. Organized into Practice Transformation Networks (PTNs), clinicians engage in peer-based learning networks to assist 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. TCPI is funded by the Centers for Medicare and Medicaid Services (CMS).

Enrollment in the NYS PTN is open to primary and specialty care providers:

  • MDs, DOs, PAs, NPs, Clinical Nurse Specialists, Clinical Psychologists, LCSWs
  • Providers using a 2014 certified EHR
  • Providers not currently participating in a Medicare Shared Savings Program, Pioneer ACO Program, Multi-Payer Advanced Primary Care Program, or Comprehensive Primary Care Initiative
Free Technical Assistance
Practices interested in participating in the NYS PTN receive:

  • On-site and remote-based practice transformation services
  • Peer networking opportunities through trainings and collaborative events
  • Access to resource guides from national experts

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.

Regional Health Information Organization Connectivity

Connect Today 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). An HIE allows providers and patients to access and securely share medical information electronically.

RHIOs receive patient data from the EHRs that are used in small practices, hospitals, behavioral health organizations, community based organizations and major health systems. Practices that contribute to a RHIO can share patient data with other providers who also use the RHIO; access information about their patients who see other providers; and use 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 from specialists.
Program Alignment
RHIO connectivity can help practices be successful in current practice transformation programs:

Advanced Primary Care

Patient-Centered Medical Home

Transforming Clinical Practice Initiative

How do Practices Pay for RHIO Connectivity?

The New York State Department of Health offers an incentive through the Data Exchange Incentive Program (DEIP) to defray the cost of connecting to a RHIO. Funding support is available until September 2018 and awarded on a first-come first-serve basis.

For more information, please contact: Sydney Sasanow at ssasanow@health.nyc.gov.

Data Exchange Incentive Program: Eligibility Requirements

  • MD, DO, Dentist, NP, CNMW, PA, or Behavioral Health provider

  • Organization uses Certified EHR Technology (CEHRT) that is able to submit data to the RHIO as CCD or C-CDA

  • Organization has at least one provider that accepts Medicaid in one of the following forms: Fee for Service, Managed Care, or HARP

  • Received payment for any year or stage of either the Medicaid or Medicare Meaningful Use Program

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