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Our Projects

Based on our Community Needs Assessment, Bronx Health Access has chosen to participate in 10 projects, which focus on three areas: Systems Transformation, Clinical Improvement, and Population Health Management.

Domain 2: System Transformation

2.a.i. Integrated Delivery System

Project Objective: To create an Integrated Delivery System focused on Evidence-Based Medicine and Population Health Management.

PMO: Steve Maggio
Community Co-Lead: Debbie Lester, Urban Health Plan
BLHC Co-Lead: John Coffey, MD

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2.a.iii Health Home At-Risk Intervention Program

Proactive Management of Higher Risk Patients Not Currently Eligible for Health Homes through Access to High Quality Primary Care and Support Services

Project Objective: To expand access to community primary care services and develop integrated care teams (physicians and other practitioners, behavioral health providers, pharmacists, nurse educators and care managers from Health Homes) to meet the individual needs of higher risk patients.

PMO: Suehane Sanchez
Community Co-Lead: 
Stephen Williams, BrightPoint Health
BLHC Co-Lead: 
David Ferris, MD & Maribel Montanez, RN

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2.b.i Ambulatory ICUs

Project Objective: To create Ambulatory ICUs for patients with multiple co-morbidities including nonphysician interventions for stabilized patients with chronic care needs.

PMO: Suehane Sanchez
Community Co-Lead: Debbie Lester, Urban Health Plan
BLHC Co-Lead: Jeffrey Levine, MD & Rachel Wolfe, PHD

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2.b.iv Care Transitions Intervention Model to Reduce 30-Day Readmissions for Chronic Health Conditions

Project Objective: To provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients at high risk of readmission, particularly patients with cardiac, renal, diabetes, respiratory and/or behavioral health disorders. 

PMO:  Suehane Sanchez
BLHC Project Lead: Natalie Cruz, RN & Reena Agarwal, MD

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Domain 3: Clinical Improvement

3.a.i (Behavioral Health) Integration of Primary Care and Behavioral Health Services

Project Objective: To integrate mental health and substance abuse with primary care services to ensure coordination of care for both services. 

PMO: Kathy Alexis
Community Co-Lead: Terri Udolf, St. Christopher's Inn
Community Co-Lead: Debbie Pantin, VIP Severices
BLHC Co-Lead: Vicente Liz-Defillo, MD

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3.c.i (Chronic Disease Management) Implementation of Evidence-Based Strategies in the Community to Address Chronic Disease—Primary and Secondary Prevention Projects (Adults Only)

Project Objective: To support implementation of evidence-based best practices for disease management in medical practice related to diabetes. 

PMO: Kathy Alexis
Community Co-Lead: Manual Vazquez, MD, Urban Health Plan
BLHC Co-Lead: Abayomi Salako, MD

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3.d.ii (Chronic Disease Management) Expansion of Asthma Home-Based Self-Management Program

Project Objective: To implement an asthma self-management program including home environmental trigger reduction, self-monitoring, medication use, and medical follow-up to reduce avoidable ED and hospital care.

PMO: Kathy Alexis
Community Co-Lead: Scott Auwarter, BronxWorks
BLHC Co-Lead: Peter Sherman, MD

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3.f.i (Premature Birth) Increase Support Programs for Maternal and Child Health (Including High Risk Pregnancies)

Project Objective: To reduce avoidable poor pregnancy outcomes and subsequent hospitalization as well as improve maternal and child health through the first two years of the child’s life.

PMO: Kathy Alexis
BLHC Co-Lead: Magdy Mikhail, MD
BLHC Co-Lead: Glenys Thomas Perales

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Domain 4: Population–Wide

4.a.iii (Behavioral Health) Strengthen Mental Health and Substance Abuse Infrastructure across Systems

Project Objective: To strengthen mental health and substance abuse infrastructure across systems. 

PMO: Duane Granston
Community Co-Lead: Debbie Patin, VIP Services
BLHC Co-Lead: Vicente Liz-Defillo, MD
BLHC Co-Lead: Lenny Vincente

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4.c.ii (HIV) Increase early access to, and retention in, HIV care (Focus Area 1; Goal #2)

Project Objective: To increase early access to, and retention in, HIV care.

PMO: Duane Granston
Community Co-Lead: Debbie Witham, VIP Services
BLHC Co-Lead: Richard Cindrich, MD
BLHC Co-Lead: Lenny Vincente

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