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.
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
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.
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