NYC REACH

Advancing Primary Care and Community Health

ABOUT US

Primary Care is foundational to achieving health equity. NYC REACH advances primary care through
support and innovation at the NYC Department of Health and Mental Hygiene.

NYC REACH partners with providers and organizations to:

Implement innovative and patient-centered strategies for chronic disease prevention & management

Optimize digital technology and electronic health record interoperability for efficiency

Create clinical and community linkages to address social determinants of health

Integrate behavioral health in addressing physical health

Align with payment reform for sustainability and fiscal strength

Build healthcare worker capacity and promote team-based approaches

Inform policy changes and translate to practical application

Advance NYC Health Department Chief Medical Officer’s anti-racism commitment

NYC REACH is operated by the Bureau of Equitable Health Systems (BEHS) whose goal is to apply policy, evidence, and practical expertise to improve equity in health care delivery at the individual, organizational, and systems levels. BEHS is a bureau of the Center for Health Equity and Community Wellness division. NYC REACH was originally created in 2010 to serve as the city’s regional extension center for health information technology (HIT) and support clinical settings in adopting and using electronic health records (EHRs) for population health.

NYC REACH is a free membership organization, primarily funded by state and federal contracts and grants. Staff are trained and experienced practice facilitators who provide direct technical assistance to providers and organizations. NYC REACH is guided by an advisory council of physicians from a variety of healthcare institutions across New York City.

MEET OUR TEAM

Duncan Maru, MD, PhD

Assistant Commissioner, Bureau of Equitable Health Systems

Duncan Maru, MD, PhD, serves as the Assistant Commissioner for the Bureau of Equitable Health Systems (BEHS) in the Center for Health Equity and Community Wellness (CHECW). BEHS works with primary care providers, hospitals, payors, and other healthcare systems to address structural racism and implement evidence-based strategies. Dr. Maru is an epidemiologist and physician trained in internal medicine and pediatrics and an Associate Professor in the Department of Global Health at Mount Sinai. He also continues to teach and practice clinically at NYC Health + Hospitals / Elmhurst Hospital Center.

Samantha De Leon, PHD

Executive Director, Program Evaluation and Planning

Samantha De Leon serves as the Executive Director of Program Evaluation and Planning for the Bureau of Equitable Health Systems. She is responsible for managing the Evaluation, Research, and Analytics team that conducts program evaluation and research on the impact of health information technology, quality improvement incentives, and activities on patient quality of care in the primary care setting across New York City. Samantha and her team use a variety of data sources including electronic health records data, Medicaid and ambulatory clearinghouse claims, surveys, and primary data collected through various program initiatives. She received her PhD in epidemiology/environmental medicine from New York University School of Medicine.

Ernesto Fana, MPA

Executive Director, Community Healthcare Support

Ernesto Fana serves as the Executive Director of Community Healthcare Support for the Bureau of Equitable Health Systems. He oversees efforts to engage and support community providers with their quality improvement goals. His team provides technical assistance with electronic health record optimization and facilitates changes to patient care workflows, using small, rapid cycles of change to achieve clear objectives. Ernesto’s team also works with over 400 select practices on targeted quality improvement initiatives that focus on diabetes, hypertension, and smoking cessation. He received his MPA in Public Affairs and Administration from Metropolitan College of New York.

Janice Magno, MPA

Executive Director, Community Healthcare Strategic Partnerships

Janice Magno serves as the Executive Director of Community Healthcare Strategic Partnerships for the Bureau of Equitable Health Systems. She leads a portfolio of practice transformation initiatives aimed at strengthening the primary care delivery system. She manages a team that provides technical assistance to practices in medical home transformation and preparation for value-based payment. She also oversees BEHS’ collaboration with payers, accountable care organizations, qualified entities, government agencies, and other partners. Janice received her MPA in health policy and management from New York University’s Wagner Graduate School of Public Service.

Emily Carroll, MPH

Director, Communications and Operations

Emily Carroll serves as the Director of Communications and Operations for the Bureau of Equitable Health Systems. Her team specializes in creating and disseminating content, hosting events and trainings, and outreach to clinicians who are eligible to join quality improvement and value-based payment programs. She is responsible for developing strategic communications, outreach, and engagement plans to meet programmatic goals. Emily received her MPH in health policy and management at CUNY Graduate School of Public Health & Health Policy.

Sonali Das, MPH, MSW

Senior Program Evaluator, Program Evaluation and Planning

Sonali Das is a Senior Program Evaluator on the Program Evaluation and Planning team for the Bureau of Equitable Health Systems. She evaluates chronic disease prevention and management programs, primary care quality improvement initiatives, and health equity initiatives using survey and qualitative methodologies. Sonali received her MPH from the CUNY Graduate School of Public Health & Health Policy and her MSW from New York University.

Carlos Devia, PhD

Director, Strategic Projects

Carlos Devia serves as the Director of Strategic Projects for the Bureau of Equitable Health Systems. He oversees field teams that work with over 80 community health centers, including Federally Qualified Health Centers, hospital ambulatory centers, multispecialty care centers, and urgent care centers implementing innovative care delivery models that utilize Health IT, value-based care, and person-centered approaches. Carlos is responsible for implementing clinical quality improvement programs that address inequities in cardiovascular disease, expanding patient-facing services for NYC DOHMH’s ADCES-accredited diabetes education and support program, and providing equitable access to vaccination services for COVID-19, flu, and other routine vaccines in NYC neighborhoods disproportionately affected by the COVID-19 pandemic. He received his PhD in Community Health and Health Policy from CUNY School of Public Health and Health Policy.

Maria Fernandez Galvis, MSW

Manager, Clinical Community Program Linkages

Maria Fernandez Galvis serves as the Clinical Community Linkages Manager for the Bureau of Equitable Health Systems. She oversees efforts to engage clinical and community organizations to increase access to chronic disease prevention and self-management programs. Her team provides training and technical assistance to assist organizations in increasing their capacity to implement and sustain lifestyle self-management programs and develop pathway referrals across the health system. Maria’s team also provides resources for organizations to offer culturally and linguistically responsive programs to engage populations experiencing the highest risk and prevalence of diabetes, hypertension, and severe maternal morbidity. Maria received her MSW from Lehman College.

Matt Gannon

Director, Care Transformation

Matt Gannon serves as Director of Care Transformation for the Bureau of Equitable Health Systems. His team works directly with providers, health centers, and hospital sites on medical home transformation, Health IT optimization, and value-based payment programs. Matt’s team supports over 200 primary care sites to make strategic enhancements to improve care coordination, increase patient satisfaction, and take a data-driven approach to performance improvement. Matt holds a Bachelor’s degree from Ramapo College of New Jersey.

Lily Glenn, MPH

Senior Evaluator, Program Evaluation and Planning

Lily Glenn is a Senior Evaluator on the Program Evaluation and Planning team for the Bureau of Equitable Health Systems, where she conducts mixed methods program evaluations focused on chronic disease prevention and management. Lily also contributes to policy-relevant health equity research and evaluation projects. She received her MPH from the Mailman School of Public Health at Columbia University.

Matt Krco

Data Operations Manager, Program Evaluation and Planning

Matt Krco serves as the Data Operations Manager on the Program Evaluation and Planning team for the Bureau of Equitable Health Systems. Matt and his team maintain the data infrastructure at BEHS, ensuring that our teams have accurate, reliable, and actionable data to inform all aspects BEHS’ operations, from practice facilitation to program evaluation. His team can be found developing integrations with new data sources, creating advanced reporting and analytics, improving efficiency by automating manual tasks, and much more. Matt has a bachelor’s degree in statistics from the University of Wisconsin-Madison.

Charlene Ngamwajasat, MD

Senior Physician Informaticist and Population Health Clinical Advisor, Program Evaluation and Planning

Charlene Ngamwajasat, MD serves as the Senior Physician Informaticist and Population Health Clinical Advisor for the Bureau of Equitable Health Systems. She leads clinical quality initiatives, supports strategic planning around population health initiatives, and provides interprofessional trainings. Dr. Ngamwajasat is a graduate of the Sophie Davis School of Biomedical Education, received her MD from SUNY Downstate, and completed her internal medicine residency at Lenox Hill Hospital. She is also board certified in clinical informatics.

Patrick Powell

Director, HIT Workflow and Implementation

Patrick Powell serves as the Director of Health Information Technology Workflow and Implementation for the Bureau of Equitable Health Systems. He is responsible for the planning, developing, and implementation of new procedures to assist in developing short- and long-range plans for data related project goals. His team works to provide coordination between BEHS teams to maximize how data is obtained from the 400 providers, health centers, and hospital sites that are part of quality improvement initiatives. Patrick Powell holds a Bachelor’s degree from Howard University, School of Business.

Ellie Rogowski

Director, Community Healthcare Support

Ellie Rogowski serves as Director of Community Healthcare Support for the Bureau of Equitable Health Systems. Ellie and her team participate in planning, developing, and implementing new workflows and procedures across the team related to grant deliverables, project implementation, and administrative related activities. She is responsible for managing several grants across funding partners, as well as identifying new grant and funding opportunities for the team. She also collaborates with internal and external stakeholders, including Fund for Public Health NYC, to assist in developing short and long-range plans for accomplishing team goals. Ellie holds a Bachelor’s degree in Public Health from James Madison University and is currently pursuing her doctor of health sciences (DHSc).

Vitaliy Shtutin, CRN, MPH

Director, Trainings and Clinical Workflows

Vitaliy Shtutin serves as the Director of Trainings and Clinical Workflows for the Bureau of Equitable Health Systems. He is responsible for the management and direction of Clinical Quality Workflows to ensure alignment with project goals and the health department’s overall mission. His team provides internal and external stakeholders with training on new protocols, technology and workflows aimed at the improved management of chronic illness as well as technical assistance. Vitaliy Shtutin is a Certified Registered Nurse graduate from Pace University, Lienhard School of Nursing, Center for Continuing Education in Nursing and Health Care and trained in geriatrics and internal medicine. He also holds an MPH from St. Petersburg State Academy of Medical Pediatrics.

Bahman Tabaei

Director, Primary Care Surveillance

Bahman Tabaei serves as the Director of Primary Care Surveillance for the Bureau of Equitable Health Systems. He is responsible for designing and conducting advanced analysis by employing multiple complex clinical and population level data sources including electronic health records, surveys, vital statistics and primary data collected through numerous program initiatives. The main focus of his work is to evaluate the impact of public health programs, quality improvement activities and health care-community partnerships on the primary care patient populations and health outcomes. Bahman and his team also provide support in the development of new grant proposals, evaluation plans, and studies intended to support city-wide public health interventions and the bureau’s programmatic work and effort to combat health inequities in New York City. He received his MPH in epidemiology from the University of Michigan School of Public Health.

Jennifer White, MPH

Director, Quality Improvement

Jennifer White serves as the Director of Quality Improvement at the Bureau of Equitable Health Systems. She oversees a team of Practice Facilitators who provide quality improvement support to over 400 primary care practices and pharmacies. Her team uses evidence-based strategies to streamline workflows and improve patient health outcomes, for hypertension, diabetes, and smoking cessation. Jennifer received her MPH in public health geographic information sciences at the CUNY Graduate School of Public Health & Health Policy.

Staff List

Alexandra Bragg

Senior Care Transformation Specialist • Community Healthcare Strategic Partnerships

Allison Foley

Community Health Worker • Community Healthcare Support

Alyssa Berkowitz

Evaluation Analyst • Program Evaluation and Planning

Amanda Spence

Sr. Manager Program Partnerships • Community Healthcare Support

Bay Ouma

Community Health Worker • Community Healthcare Support

Cassidy Charlot

Program Coordinator • Community Healthcare Strategic Partnerships

Chi Crawford

Community Health Worker • Community Healthcare Support

Chien Ting Chen

Clinical Quality Manager • Community Healthcare Support

Courtney Chan

Senior Clinical and Population Health Data Analyst • Program Evaluation and Planning

Dharani Krishnan

Salesforce Administrator • Program Evaluation and Planning

Diane Jones

Executive Assistant • Bureau of Equitable Health Systems

Dominique Gabriel

Senior Care Transformation Specialist • Community Healthcare Strategic Partnerships

Donald Olson

Senior Epidemiologist • Program Evaluation and Planning

Donna Castelblanco

Manager, Care Transformation • Community Healthcare Strategic Partnerships

Ernest Gong

Finance and Operations Manager • Community Healthcare Strategic Partnerships

Evette Dejesus

Diabetes Prevention Outreach Specialist • Community Healthcare Support

Frederich Gautreau

Health IT Workflow Project • Community Healthcare Support

Gila Stadler

Senior Care Transformation Manager • Community Healthcare Strategic Partnerships

Gloria Alfonso

Practice Facilitator • Community Healthcare Support

Hanna Liriano

Clinical-Community Linkages Specialist • Community Healthcare Support

Hannah Marcus

Data Analyst • Program Evaluation and Planning

Hima Bindu Moka

Salesforce Solutions Architect and Manager • Program Evaluation and Planning

Indrani Rivera

Events Specialist • Community Healthcare Strategic Partnerships

Jennifer De Leon

Clinical Community Linkages Specialist • Community Healthcare Support

Joohee Suh

Strategic Projects Specialist • Community Healthcare Strategic Partnerships

Joselyn Olacio

Prevention Outreach Specialist • Community Healthcare Support

Katherine Nowak

Program Coordinator • Community Healthcare Support

Keisha Haynes-leith

Clinical Quality Specialist • Community Healthcare Support

Kyla Dayer

Senior Care Transformation Specialist • Community Healthcare Strategic Partnerships

Lillian Diaz

Community Health Worker • Community Healthcare Support

Marleny Peguero

Community Health Worker • Community Healthcare Support

Marie Barrett

Community Health Worker • Community Healthcare Support

Mercelinda Fernandez

Community Quality Specialist • Community Healthcare Support

Mikayla Hyman

Strategic Projects Specialist • Community Healthcare Strategic Partnerships

Monisha Alummoottil

Practice Facilitator • Community Healthcare Support

Natalie Polinsky

Communications and Outreach Manager • Community Healthcare Strategic Partnerships

Natoya Worrell-Gooding

Clinical Quality Specialist • Community Healthcare Support

Phoenix Maa

Data Operations Specialist • Program Evaluation and Planning

Qun Jiang

Director of A1C Registry Surveillance • Program Evaluation and Planning

Rachel Lima

Program Manager • Community Healthcare Support

Rahim McNeilly

Communications and Outreach Specialist • Community Healthcare Strategic Partnerships

Rochelle Stewart

Program Manager Patient Engagement • Community Healthcare Support

Roxana Yusti

Clinical Community Linkages Sr. Specialist • Community Healthcare Support

Sachel Somwaru

Senior Clinical Quality Manager • Community Healthcare Support

Salomon Angulo

Prevention Outreach Specialist • Program Evaluation and Planning

Samantha Witchey

Programs and Administration Manager • Community Healthcare Support

Sarah Perl

Behavioral Health Integration Educator • Community Healthcare Support

Sarah Stankiewicz

Program Operations Specialist • Community Healthcare Support

Sergey Menkoff

SQL Server Developer • Program Evaluation and Planning

Shaun Hui

Manager, Diabetes Management and Support • Community Healthcare Strategic Partnerships

Shirley Chapman

Care Transformation Specialist • Community Healthcare Strategic Partnerships

Shivani Jarathi

Salesforce Administrator/Jr. Developer • Program Evaluation and Planning

Shivana Seeram

SDOH Workforce Development Program Manager • Community Healthcare Support

Sparkle Johnson

Clinical Quality Manager • Community Healthcare Support

Sruthi Venigalla

Senior Manager, Community Health Systems • Community Healthcare Support

Tamara McFarland

Senior Database Manager/Architect • Program Evaluation and Planning

Tracey McGruder

Sr. Clinical Quality Specialist • Community Healthcare Support

Wasefa Gioia

Community Health Worker • Community Healthcare Support

Xuming Sun

Senior Analyst • Program Evaluation and Planning

IMPACT

Since its inception in 2010, NYC REACH has strived to help providers fully utilize Health Information Technology. Through 2019, 26,000 providers in New York City have joined NYC REACH. NYC REACH has helped community health centers, foster care agencies, hospitals, and small practices receive over $465 million in incentive payments paid through multiple initiatives.

1800

Primary care practices

Patients served by NYC REACH
member organizations

100

Community Health Centers and Community-Based Organizations

250

Pharmacies

The dots on this map represents the distribution of NYC REACH members across the five boroughs. The grey-shaded neighborhoods are part of the Taskforce on Racial Inclusion & Equity (TRIE). These neighborhoods were disproportionately impacted by COVID-19 and the taskforce designation allows the neighborhoods to be prioritized for assistance. NYC REACH supports the NYC Department of Health and Mental Hygiene’s goals for health equity by partnering with organizations in impacted neighborhoods.

CERTIFICATIONS

Partner in Quality for Patient-Centered Medical Home certification

Diabetes Education Accreditation Program for diabetes self-management education and support (DSMES)

Patient-Centered Medical Home Certified Content Experts

Membership

Interested in joining our network? Joining is easy!

NYC REACH membership is free to all New York City providers and practices.

CAREERS

Join a team that encourages creativity and collaboration! We’re looking for talented individuals who are passionate about improving the health of New Yorkers. Through BEHS’ partnership with the Fund for Public Health in New York City (FPHNYC), a not-for-profit organization that collaborates with the New York City Department of Health and Mental Hygiene to implement and advance public health initiatives, we have exciting opportunities available. To find out about BEHS positions at FPHNYC, please visit http://www.fphnyc.org/get-involved/joinourteam/ and review the positions listed under “Equitable Health Systems.”

PHYSICIAN ADVISORY COUNCIL

The Physician Advisory Council is a group of providers who provide input on the Bureau of Equitable Health System’s many projects, programs, and services. The council consists of members representing small and large practices all throughout New York City and assists BEHS with understanding the healthcare landscape of the City.

Robert Adler

Segulah Pediatrics

Ruchi Agarwal

Well Care OB/GYN

Rita Ahuja

Perry Ave Family Medical

Jose Aristy

Jose D. Aristy MD PC

Qudsia Banu

Brookdale Family Care Center Eastern Parkway

Marie Belotte

Cross County Medical Care PC

Avi Bitton

M. Avi Bitton MD PC

Terry Blackett-Bonnett

T. Bonnett Medical Services PC

Bina Chaudhari-Mody

Bina Chaudhari-Mody MD PC

Lisa Eng

New Life Medical Esthetics and Wellness

Ahmed Haider

Preferred Medical Care NY PC

Patricia Hart

Patricia M. Hart MD

Mohamed Helal

Global Medical Care PC

Gabriela Henriquez

Kidney Medical Associates

Margaret Kearns-Stanley

Margaret Kearns-Stanley MD PLLC

Hylton Lightman

Total Family Care

Bing Lu

Universal Medical Service LLC

Frank Maselli

Riverdale Family Practice

George McMillan

Choices Women’s Medical Center

Robert Morrow

Robert W. Morrow MD PC

Eliza Ng

CAIPA

Christiana Nichols

Nichols Pediatrics

Kevin Norowitz

Integrated Medical Health

Regina Olasin

Care for the Homeless

Maxine Orris

Wyckoff Doctors

Tosan Oruwariye

Tiga Pediatrics

Iffat Sadique

Prime Care Medical Group PC

Ruma Sanyal

Queens Medical Services PC

Saulius Skeivys

Saulius J. Skeivys MD PC

Jeffrey Teitelbaum

Jeffrey L. Teitelbaum MD PC

Gerald Weber

Murray Hill Podiatric Associates

San San Wynn

San San Wynn MD PC