Quality Improvement Services


NYC REACH can guide a practice in choosing a Certified EHR that best fits their needs.


Clinical Specialty Support
Customer Support Services
Public Health Reporting Capabilities Content (e.g. immunization registry, syndromic surveillance, cancer registries)
Implementation timelines (how quickly the system can be installed, tested and turned on in your practice)
Available integration with lab and diagnostic companies
Ability to exchange information with other EHR systems and Health Information Exchanges (HIEs)
Reporting capabilities for participating programs such as Meaningful Use, Accountable Care Organizations, and Patient Centered Medical Home

NYC REACH offers educational materials to connect a practice to resources that will help in the decision of which EHR will best serve the practice.
For help starting your EHR system search, contact NYC REACH today!

Meaningful Use

What is Meaningful Use?

Meaningful Use, also known as the New York State Medicaid EHR Incentive Program, is a Centers for Medicare and Medicaid Services (CMS) Promoting Interoperability Program. The program gives financial incentives to providers who demonstrate “Meaningful Use” of certified electronic health record technology (CEHRT). The program’s objectives require providers to use an EHR system to capture patient data, and engage with patients and other providers to support and coordinate patient care.

The program is active through 2021.

Why should I participate?
  • Providers who see more than 30% Medicaid patients can earn up to $63,750 in total incentive payments for six years of participation in the program.
  • Providers can earn up to $8,500 for each year that they successfully achieve Meaningful Use.
  • Providers who achieve Meaningful Use establish a necessary foundation for other quality improvement and incentive programs supporting value-based care, care coordination, and quality improvement.
  • Federal and state programs that are shifting towards value-based payment arrangements include the Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS), and New York State Patient-Centered Medical Home (NYS PCMH).
1. Determine Eligibility

Eligible* provider types:

  • Physicians (MD, DO)
  • Dentists (DDS, DMD)
  • Nurse Practitioners (NP)
  • Certified Nurse-Midwives (CNMW)
  • Physician Assistants (PA) who furnish services in a Federally Qualified Health Center (FQHC) or Rural Health Clinical that is led by a PA

*These provider types are eligible for Meaningful Use if they are not hospital-based practitioners. Hospital-based practitioners are defined as providers who see more that 90% of patients as hospital inpatients or ED visits are considered hospital-based.

Eligibility also depends on an EP’s level of participation previous years.

  • Eligible providers can only receive payments for six years of Meaningful Use. Eligible providers who successfully attested and received payments for six years prior to 2018 are unable to continue participating in the program after 2018.
  • Eligible providers who have not attested prior to 2016 cannot join the program.
  • Eligible providers must have received and kept at least one incentive payment for performance year 2016 or earlier. Incentive payments that were returned due to a failed audit cannot be counted.

Medicaid Patient Volume

Providers are eligible to participate if the Medicaid Patient Volume reporting period is 90 days and 30% of encounters are Medicaid patients (20% for pediatricians).

To learn more information about eligibility, visit the CMS website.

2. Adopt Certified EHR Technology

Eligible providers must use an EHR that is certified by the CMS and the Office of the National Coordinator for Health Information Technology (ONC). Certified Electronic Health Record Technology (CEHRT) offers providers the necessary technological capabilities and security to help meet Meaningful Use criteria. To determine if an EHR system is currently certified, view the ONC Certified Health IT Product List (CHPL).

CEHRT requirements are different for Modified Stage 2 and Stage 3 Meaningful Use. NYC REACH can guide a practice in choosing a Certified EHR that best fits their needs. Contact NYC REACH today to start your EHR system search.

3. Meet Meaningful Use Requirements

Providers must meet specific required measures and document data in the EHR to attest to Meaningful Use

Meaningful Use
Modified Stage 2 Objectives
Meaningful Use
Stage 3 Objectives
1. Protect Patient Health Information 1. Protect Patient Health Information
2. Clinical Decision Support 2. Electronic Prescribing
3. Computerized Provider Order Entry 3. Clinical Decision Support
4. Electronic Prescribing 4. Computerized Provider Order Entry
5. Health Information Exchange 5. Patient Electronic Access
6. Patient-Specific Education 6. Coordination of Care
7. Medication Reconciliation 7. Health Information Exchange
8. Patient Electronic Access 8. Public Health Reporting
9. Secure Electronic Messaging
10. Public Health Reporting
4. Attest

All participating providers must successfully demonstrate Meaningful Use by submitting EHR data and Medicaid Patient volume information through MEIPASS, New York State’s EHR Incentive Payment System. The State will review the submission and determine if the provider will receive an incentive payment.


Meaningful Use participants can earn up to $63,750 for six years of participation. Incentive payments are time-sensitive and require measures to be met within a particular timeframe each year. Providers can earn up to $8,500 for each year that they successfully achieve Meaningful Use.

Providers are required to demonstrate Meaningful Use each year to receive an incentive payment.

Additional Services

As the healthcare industry shifts to value-based care, NYC REACH wants to continue to help providers succeed in delivering the best care to their patients.
NYC REACH supports providers through participation in programs around accountable care, patient-centered care and targeted improvements on public health priorities.

NYC REACH has services to help practices improve care coordination, patient engagement, and utilize health information systems, such as electronic health records (EHRs), to follow-up and monitor the health of their patient populations.

Support is offered for:

 Clinical-Community Program Linkages

Clinical-Community Program Linkages (CCPL) is an initiative that fosters connections between clinical and community programs. The goal of CCPL is to develop sustainable and scalable pathways from the clinical environment to evidence-based intervention programs.

CCPL aims to:

  • Collaborate with providers and community partners to increase evidence-based intervention program referrals
  • Support clinical organizations and worksites with offering evidence-based intervention programs
  • Increase patient participation in evidence-based intervention programs
Evidence-Based Interventions

CCPL assists with generating clinical referrals and setting up workshops for the following evidence-based intervention (EBI) programs.


Patients Referred


NYC Practices Referring Patients


Lifestyle Coaches Trained


EBI Program Workshops Hosted by Partner Organizations

National Diabetes Prevention Program

The National Diabetes Prevention Program (National DPP), which uses a Centers for Disease Control and Prevention (CDC)-approved curriculum, is an evidence-based lifestyle change prevention program for adults who have prediabetes or are at high risk for developing type 2 diabetes. Adults with prediabetes have blood sugar levels that are higher than normal but not high enough to be diagnosed with type 2 diabetes.

The year-long program consists of 16 one-hour weekly sessions followed by monthly maintenance sessions. The program is facilitated by a certified lifestyle coach who follows the CDC-approved curriculum, which includes concepts related to physical activity, coping mechanisms, healthy eating, and stress management.

The overall objective of the National DPP is for participants to lose at least 5% of their body weight and adopt healthier lifestyle habits.


All program materials are available in English and Spanish on the CDC website.

In order to make the program more accessible to New York City’s diverse population, these materials have been translated into Bengali, Haitian Creole, and Korean.

Organizations interested in hosting the program can click on the links below to download the leader curriculum or participant curriculum in each language. Each curriculum includes content for the core sessions (the first six months of the program) and maintenance sessions (the second six months of the program).

নেতৃত্ব পাঠ্যক্রম: বাংলা
অংশগ্রহণকারী পাঠক্রম: বাংলা

Leader Curriculum: English
Participant Curriculum: English

Pwogram pou Dirijan: Kreyòl Ayisyen
Pwogram pou Patisipan: Kreyòl Ayisyen

리더 교육 과정: 한국어
참여자 교육 과정: 한국어

Plan de estudios del líder: Español
Plan de estudios del participante: Español

Additional program materials including fitness and food logs, action plans, and certificates, are also available in each language. Contact NYC REACH to learn more.


National DPP providers can bill Medicare for services under the expanded Medicare Diabetes Prevention Program (MDPP) model. The MDPP expanded model includes an evidence-based set of services aimed at preventing the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. Beginning April 1, 2018, MDPP services are covered for eligible beneficiaries with no cost-sharing through Medicare-enrolled MDPP suppliers.

Click here to download a guide to enrolling in Medicare as an MDPP Supplier.

Diabetes Self-Management Program

The Diabetes Self-Management Program (DSMP), supported by the Self-Management Resource Center, is designed to assist patients in managing type 2 diabetes.

The DSMP teaches self-managed lifestyle change and coping strategies to enable participants to increase physical activity levels and manage their diabetes and medications.

Patients with type 2 diabetes attend the workshop in small groups for 2½ hours per week, for six weeks. Workshops are facilitated by two trained leaders, one or both of whom is a peer leader with diabetes.

Chronic Disease Self-Management Program

The Chronic Disease Self-Management Program (CDSMP), supported by the Self-Management Resource Center, is designed to assist patients with managing their chronic or ongoing health condition(s).

The CDSMP teaches self-managed lifestyle change and coping strategies to enable participants to increase physical activity levels and manage their health condition(s) and medications.

Patients with different chronic health conditions attend the workshop in small groups for 2½ hours per week, for six weeks. Workshops are facilitated by two trained leaders.

Referring to evidence-based intervention programs is free, easy, and aligned with many of NYC REACH’s Quality Improvement initiatives.

Quality Improvement Projects

NYC REACH’s quality improvement projects introduce innovative system changes that promote disease prevention and control through the following actions:
  • Improve blood pressure control among hypertensive patients
  • Deliver smoking cessation interventions
  • Reduce the number of patients with uncontrolled diabetes
  • Reduce the prevalence of diabetes by increasing participation in the National Diabetes Prevention Program
  • Adopt and use health information technologies
  • Transform practices to achieve federal and state-driven initiatives for advanced primary care models

2017 – 2022

DREAM Initiative

The Diabetes, Research, Education, and Action for Minorities (DREAM) Initiative integrates community health workers into primary care practices to help prevent and manage type 2 diabetes in the South East Asian community. This initiative aims to:

  • Promote weigh loss for patients at risk
  • Reduce A1c levels among patients with uncontrolled diabetes
  • Increase use of community and social services
  • Increase diabetes-related self-efficacy

This project is a partnership with NYU Langone Medical Center.

September 2014 – September 2018

Join the BEAT

Join the BEAT’s goal is to integrate community-based programs and resources with medical practice-based quality improvement to promote hypertension control and diabetes prevention. The program has an emphasis on neighborhoods within areas of the District Public Health Offices and Southeast Queens. BEAT stands for:

  • Be Active
  • Eat Healthy
  • Act on Your Cardiovascular Risks
  • Take Your Prescribed Medication

September 2013 – December 2018


NYC Care Calls helps patients control their diabetes through consistent telephonic interventions intended to promote long-term behavioral change. Topics discussed during these telephonic self-management support calls include:

  • Medication Adherence
  • Healthy Eating
  • Physical Activity
  • Community Resources

This project is a partnership with the Albert Einstein College of Medicine.

Began September 2015

Public Health Detailing Action Kits

NYC REACH is involved with the development and dissemination of Public Health Detailing Action Kits. These kits, made up of clinical tools and resources for both patients and providers, promote evidence-based best practices and chronic disease management. Some topics discussed by the detailing action kits include:

  • Diabetes
  • Hypertension
  • Behavioral Health
  • Smoking Cessation

Click here for more information on these and other detailing action kits. 

June 2015 – December 2018

HealthyHearts NYC

HealthyHearts NYC aims to improve cardiovascular disease prevention and treatment in primary care by focusing on the ABCs of cardiovascular care:

  • Aspirin as Appropriate
  • Blood Pressure Control
  • Cholesterol Management
  • Smoking Cessation

Healthy Hearts is a partnership with NYU Langone Medical Center (NYULMC) and the Community Health Care Association of New York State (CHCANYS).