Quality Improvement Services

EHR Optimization and Practice Facilitation

NYC REACH quality improvement (QI) specialists work personally with providers and practice staff to establish and achieve quality improvement goals. QI specialists help practices optimize their electronic health record (EHR) systems to improve practice workflows and provide the best care possible.

EHR optimization and practice facilitation services include:
Group trainings on EHR system features and best practices, based on skill level
Onsite technical assistance and training on EHR system setup and features
Assistance with patient care workflow and practice workflow redesign
Guidance on how to generate and interpret practice data to improve quality measures
Support with EHR system upgrades and maintenance

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.

Patient Engagement Programs

Patient Engagement Programs at NYC REACH address premature mortality, racial inequities, and quality of life related to diabetes, hypertension, and maternal morbidity. These programs connect clinical and community organizations – and their patients and clients – to evidence-based chronic disease prevention and management programs. The PEP group at NYC REACH manages NYC Care Calls and Clinical-Community Program Linkages.


NYC Care Calls

NYC Care Calls is an evidence-based, telephonic self-management support program for patients with type 2 diabetes. Bilingual health educators provide education and support over a series of six calls to help patients implement their diabetes care plans. Topics include medication adherence, healthy eating, physical activity and stress management.

Referring to NYC Care Calls is free, easy, and aligned with many of NYC REACH’s Quality Improvement initiatives. Contact us to learn more.

Clinical-Community Program Linkages

The Clinical-Community Program Linkages (CCPL) team at NYC REACH foster connections between clinical and community settings to develop sustainable and scalable pathways from clinics and the community to evidence-based chronic disease prevention and management programs.

The CCPL team:

  • Increases participation in programs
  • Supports clinical and community organizations, including worksites, with offering programs
  • Collaborates with clinical and community partners to increase program referrals

Click here to find events supported by the CCPL team.

Evidence-Based Chronic Disease Prevention and Management Programs

The Clinical-Community Linkages team assists with generating referrals and setting up the following programs. Each program is delivered by a certified lifestyle coach who follows a standard curriculum but tailors the workshops to reflect the cultural diversity of participants.

National Diabetes Prevention Program

The National Diabetes Prevention Program (National DPP) is an evidence-based lifestyle change program for adults who have prediabetes or are at risk for type 2 diabetes. The National DPP uses the PreventT2 curriculum, developed by the Centers for Disease Control and Prevention (CDC), and is proven to help adults make the lifestyle changes to reduce their risk for type 2 diabetes by 58 percent.

In this year-long workshop, participants meet weekly for the first 6 months, then once or twice a month for the second 6 months. The workshops are led by certified lifestyle coaches, who empower participants to take charge of their health and well-being. The lifestyle coaches cover topics 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 five to seven percent of their body weight and adopt healthier lifestyle habits.

  • Click here for the English version of the National DPP Participant Guide.
  • Pulse aquí para ver la Guía del participante del DPP en español.


The National DPP is a covered benefit for Medicare and Medicaid beneficiaries. Organizations that are recognized by the CDC as National DPP service providers are eligible to receive reimbursement for National DPP services. Eligible organizations include clinical organizations, community-based organizations, and faith-based organizations.

  • Click here to learn how to enroll in Medicare as a Medicare DPP Supplier.
  • Click here to learn how to enroll in Medicaid as a National DPP Supplier.


Program session guides and additional materials for lifestyle coaches and participants are available on the NYC REACH website in English and Spanish. 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, the curriculum has been translated into Bengali, Haitian Creole, and Korean. 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 (SMRC), helps patients manage their type 2 diabetes.

The DSMP teaches patients with type 2 diabetes self-managed lifestyle changes and coping strategies to increase physical activity levels and manage their diabetes and medications.

Participants attend workshops in small groups for two and a half hours per week, for six weeks. Workshops are facilitated by two trained leaders, one or both of whom is a peer leader with diabetes.

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 (SMRC), helps patients manage their chronic or ongoing health conditions such as hypertension and heart disease.

The CDSMP teaches self-managed lifestyle change and coping strategies for patients to increase physical activity levels and manage their health conditions and medications.

Participants attend workshops in small groups for two and a half hours per week, for six weeks. Workshops are facilitated by two trained leaders. The program curriculum is available in multiple languages.

Referring to programs is free, easy, and aligned with many of NYC REACH’s Quality Improvement initiatives. Contact us to learn more.


Patients Referred


NYC Practices Referring Patients


EBI Coaches Trained


Workshops Delivered by 30+ Partners

How to refer patients

The Compass Portal is an easy and free, HIPAA-compliant online registration and referral tool. Organizations should use Compass to search for and refer patients to programs.

Compass Portal Benefits:

  • Organizations can enroll participants in programs directly, in real tim
  • Participants can choose from a selection of workshops hosted by different providers at different location
  • The referring provider can receive feedback on the participant’s attendance, physical activity, and weight loss.

Click here to access the Compass Portal.

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.


Medication Therapy Management

Medication Therapy Management (MTM) provided by pharmacists is an evidence-based approach to improving medication adherence and health outcomes. MTM is currently only covered by Medicare. NYC REACH is partnering with community pharmacies to demonstrate the feasibility and efficacy of expanding MTM services to Medicaid patients. Pharmacists offering MTM meet with patients to:

  • Review all medications, including over-the-counter medications
  • Ask how medications are working
  • Check for any problems or side effects
  • Make recommendations


Take Action ABCD

Take Action ABCD supports primary care providers and pharmacies with the implementation of innovative, evidence-based strategies to improve the health of adult residents of New York City, particularly those living in priority neighborhoods disproportionately affected by diabetes and cardiovascular disease. Take Action ABCD aims to improve:

  • A1c control
  • Blood pressure control
  • Cholesterol management
  • Diabetes prevention

This project is supported by the Centers for Disease Control and Prevention. It is a continuation of Join the BEAT.

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

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).

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. 

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: