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Cover Page

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Project Design Grant Application

There will be no extensions for this application. Any application submitted past the due date will not be considered.

Section 1 Lead Applicant Info & Project Point of Contact Section 6 List of VendorsSection 2 Partner Organization - Contact Info Section 7 Design Grant TimelineSection 3 Partner Organizations & Service Area Section 8 Data RequestSection 4 Project Program Overview & Description Section 9 Design Grant BudgetSection 5 Community Needs Assessment & Stakeholder Engagement ** Section 10

To understand the Project Design Grant Application, carefully and thoroughly read through the Instructions before completing this application.

Special Terms & Conditions Attachment I Attachment J

(Recommend) - PowerPoint/Webinar

DSRIP LINK:

Application Due on: June 26, 2014

Project Advisory Committee (PAC) Form - (RELOCATED)

^ Due to changes, this section has been RELOCATED and made as a separate form which still needs to be filled out and can be found on the DSRIP website under "DSRIP Project Design Grant Application".

As a reminder and an addition to the instructions, you MUST read through the following state documents which are provided on the DSRIP website (see link below).

https://www.health.ny.gov/health_care/medicaid/redesign/delivery_system_reform_incentive_payment_program.htm

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NYS DOH DSRIP_Project Design Grant Application Section 1 Applicant Info_Project Contact_Partner Organizations

Project Point of ContactLead Applicant Information Primary Contact

Contact Person: Sam Shutman1.1) Organization Name: Bronx-Lebanon Hospital Center Address City State Zip Code

Operating Certificate # (Opcert): Organization Address: 1276 Fulton Avenue Bronx NY 10456Provider Type: Voluntary Hospital (Non CAH, Non Sole Community Provider) Contact Phone Number: (718) 901-8920 Extension:

Provider Type - OTHER: Contact Email: sshutman@bronxleb.orgMMIS: 476022 1.4)

Billing Entity ID: Secondary ContactNPI #1: 1417027558 Contact Person: Victor DeMarcoNPI #2: Address City State Zip Code

Federal Employer ID (FEIN): Organization Address: 1276 Fulton Avenue Bronx NY 10456Contact Phone Number: (718) 901-8600 Extension:

Contact Email: vdemarco@bronxleb.org

1.2) Please provide a brief statement as to why the lead organization is qualified to serve in this capacity. ( Restricted to 3000 characters)

Characters used: 2983

1.3)

OR

#1 Is the lead applicant one of the following providers? None of the above %

OR Select One

%A. 2A 84.83

YES

B. 2B 88.25

OR

#3 NO 3

For Safety-net definition, please see link:

7000001H

Bronx-Lebanon Hospital Center (BLHC) has been a vital community resource in the South and Central Bronx for over 120 years. BLHC is an integrated health care system that includes a 579-bed acute care facility, one of the busiest emergency departments in the State, a women’s health center, a comprehensive HIV/AIDS center, major inpatient and outpatient behavioral health facilities, two nursing homes, and an extensive ambulatory care network of outpatient practices, strengthened by a cooperative agreement with the Dr. Martin Luther King, Jr. Health Center (MLK). BLHC and MLK are subrecipients of PHS Section 330 funding as part of the Bronx-Lebanon Integrated Services System, Inc. BLHC and MLK provide over 930,000 ambulatory visits, 30,000 inpatient discharges, and 120,000 Emergency Department visits annually.

BLHC has a stable management team and clinical leadership that reflect the diversity of the community. A majority of the BLHC board represents racial and ethnic minority groups, as do the boards of MLK and BLISS. BLHC is financially stable with an overall bottom line that has remained positive for more than a decade.

BLHC has extensive leadership experience in developing and successfully implementing complex, multi-partner initiatives. BLHC is the lead agency for the Bronx Health Home, a Medicaid health home that consists of over 70 organizations and provides services to 3,200 Medicaid beneficiaries. The hospital has developed the infrastructure and systems for coordinating patient care, funding the participating organizations, and communicating with providers. This Health Home is one of the most diverse in NYS, encompassing a wide array of general health, behavioral health, case management providers, housing agencies, and other social service providers. The co-lead, FEGS, as the representative of Coordinated Behavioral Care, is a key partner in BLHC’s PPS, along with many other of the participating organizations.

BLHC has a roughly 10% ownership share in Healthfirst, a not-for-profit managed care organization providing low-cost or free government-sponsored health insurance programs. BLHC is responsible for providing fully capitated health care services and care management to more than 90,000 Medicaid clients, in conjunction with community-based providers, more than any other Healthfirst provider. IPAs and community physicians who participate in the BLHC Healthfirst risk pool are also partners in the BLHC PPS. BLHC has long been a participant in both adult and pediatric NIH-sponsored HIV/AIDS clinical trials, and its Comprehensive Care Center for HIV/AIDS is widely recognized for its excellence.

Based on its successful performance in managing multi-institutional projects, its leadership expertise, the existing linkages and referral networks of the Bronx Health Home, and its history of providing culturally competent health care services, BLHC is uniquely qualified to lead the emerging PPS in the South and Central Bronx.

Based on the lead applicant provider type, please fill out the applicable section below to verify that you meet the DSRIP safety- net definition (Either Hospital OR Non-hospital based) :

Hospital: A hospital must meet one of the three following criteria to participate in a performing provider system: Non-Hospital Based Provider - Must meet the following criteria:

Not participating as part of a state-designated Health Home, must have at least 35 percent of all patient volume in their primary lines of business and must be associated with Medicaid, uninsured and Dual Eligible individuals. (Please indicate what %)

#2 - Must pass both A & B test (Please indicate what % for both tests)

At least 35 percent of patient volume in their outpatient lines of business must be associated with Medicaid, uninsured, and Dual Eligible individualsAt least 30 percent of inpatient treatment associated with Medicaid, uninsured, and Dual Eligible individuals

Must serve at least 30 percent of all Medicaid, uninsured and Dual Eligible members in the proposed county or multi-county community. (The state will use Medicaid claims and encounter data as well as other sources to verify this claim. The state reserves the right to increase this percentage on a case by case basis so as to ensure that the needs of each community's Medicaid members are met.(Please indicate what %)

https://www.health.ny.gov/health_care/medicaid/redesign/docs/safety_net_definitions.pdf

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

2.1) Partner Organizations - Contact Information

1 Organization Name: SEE UPDATED SECTION 2 FORM 2 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip Code

Organization Address: Organization Address:Contact Person: Contact Person:

Contact Phone Number: Extension: Contact Phone Number: Extension:Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

3 Organization Name: 4 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

5 Organization Name: 6 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

7 Organization Name: 8 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

9 Organization Name: 10 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

11 Organization Name: 12 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

13 Organization Name: 14 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

15 Organization Name: 16 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

17 Organization Name: 18 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

19 Organization Name: 20 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

21 Organization Name: 22 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

23 Organization Name: 24 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

25 Organization Name: 26 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

27 Organization Name: 28 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

29 Organization Name: 30 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

31 Organization Name: 32 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

33 Organization Name: 34 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

35 Organization Name: 36 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

37 Organization Name: 38 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

39 Organization Name: 40 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

41 Organization Name: 42 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

43 Organization Name: 44 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

45 Organization Name: 46 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

47 Organization Name: 48 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

49 Organization Name: 50 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

05/09/2023 document.xlsx

NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

51 Organization Name: 52 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

53 Organization Name: 54 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

55 Organization Name: 56 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

57 Organization Name: 58 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

59 Organization Name: 60 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

61 Organization Name: 62 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

63 Organization Name: 64 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

65 Organization Name: 66 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

67 Organization Name: 68 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

69 Organization Name: 70 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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71 Organization Name: 72 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

73 Organization Name: 74 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

75 Organization Name: 76 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

77 Organization Name: 78 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

79 Organization Name: 80 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 2 Partner Organizations' - Contact Info

81 Organization Name: 82 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

83 Organization Name: 84 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

85 Organization Name: 86 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

87 Organization Name: 88 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

89 Organization Name: 90 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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91 Organization Name: 92 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

93 Organization Name: 94 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

95 Organization Name: 96 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

97 Organization Name: 98 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

99 Organization Name: 100 Organization Name:Qualified Under Safety Net Definition? Select One (Please select Yes or No) Qualified Under Safety Net Definition? Select One (Please select Yes or No)

Address City State Zip Code Address City State Zip CodeOrganization Address: Organization Address:

Contact Person: Contact Person:Contact Phone Number: Extension: Contact Phone Number: Extension:

Contact Email: Contact Email:Provider Type: Select One Provider Type: Select One

Provider Type - OTHER: MMIS: Provider Type - OTHER: MMIS:Operating Certificate Number (OPCERT): Billing/Provider Entity ID: Operating Certificate Number (OPCERT): Billing/Provider Entity ID:

NPI #1: NPI #1: NPI #2: NPI #2:

Federal Employer ID (FEIN): Federal Employer ID (FEIN):

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NYS DOH DSRIP_Project Design Grant Application Section 3 Partner Organizations Service Area

Partner Organizations

3.1)Yes

Provide explanation (Restricted to 2000 characters):

Characters used: 1997

Service Area3.2) Briefly describe the proposed service area for your entire emerging Performing Provider System below. (e.g. general overview, geographic location, any notable characteristics specific to your population, etc.) ( Restricted to 3000 characters)

Do any regulations need to be waived to accomplish a DSRIP partnership within your emerging Performing Provider System?

As primary care and behavioral health services become more integrated and staff roles shift, Article 28 and Article 31 licensing regulations need to be modified to reflect the co-location of these services and allow providers to more easily establish, operate, and bill for these services. For BLHC PPS members that have co-located programs, several issues have become apparent.

Billing for co-located primary and behavioral health services-With regard to the joint licensure project, applicable rate codes need to be promulgated so that medical services in behavioral health settings (or the reverse)can reach their potential. Currently, claims with a primary behavioral health diagnosis are frequently rejected when the service is provided at an Article 28 facility. Behavioral health payers may not recognize an Article 28 site as a behavioral health site. There are no billing code options for mental health services provided by a psychiatrist or a social worker. A single category should apply for all mental health services provided in Article 28 facilities. Billing for mental health services provided by a social worker or CASAC in a primary care setting–Under current regulations, social workers can provide independent mental health treatments and bill for services only to pregnant women and children in Article 28 settings. At FQHCs, social work visits for psychotherapy cannot be reimbursed unless the medical provider also treats the patient at that visit. Under the PPS, however, there is no added reimbursement for the social worker’s services. The requirements for billing CASAC services are unclear. Billing for services provided under collaborative care models - The adoption of Project IMPACT is hampered by the absence of any methodology to bill for mental health registry review or psychiatrist consultation with primary care providers. In FQHC settings, the nurse educator effort is not reimbursed. A bundled payment for mental health team care should be pursued.

The Bronx-Lebanon Hospital Center PPS’ proposed service area spans 14 zip codes and five United Health Fund neighborhoods in the Bronx, including all of Hunts Point-Mott Haven, Highbridge-Morrisania, and Crotona-Tremont; and parts of Pelham-Throgs Neck and Fordham-Bronx Park. It encompasses neighborhoods that are predominantly minority and have high rates of poverty, unemployment, unstable housing, crime, poor health status, and premature death. Bronx County ranks last in the State in terms of health outcomes and the factors that drive health. Multiple co-occurring medical, mental health conditions and chemical dependencies are common. Access to medical care is impeded by language, immigration status, health insurance, health literacy, domestic violence, and transportation. The service area incorporates the NYC Department of Correction's facilities on Rikers Island. The total service area population (2010) includes 870,498 residents whose median age is 30 years.). The PPS service area is racially and ethnically diverse (35% African-American, 23% Caucasian, 3% Asian, and 64% Hispanic). More than a third of residents are foreign born. An estimated 32% of residents report that they speak English “less than very well.” The area is overwhelmingly low-income; mean household income is $39,288, considerably lower than NYC ($81,374) and NYS ($83,578). These neighborhoods are largely designated as HRSA Health Professional Shortage and Medically Underserved Areas.

In the South Bronx, 22% of residents are uninsured, compared to 19.8% i(NYC) and 11.3% ( NYS). State Medicaid data reveal there were 61,420 dually-eligiblebeneficiaries and 546,337 non-dual (Medicaid only) beneficiaries in the PPS proposed area in 2012; 607,757 beneficiaries in aggregate (37% children and 63% adult).

Medicaid data highlight the urgent need in the PPS service area for additional and more comprehensive primary medical care and mental health services to reduce hospitalizations and ED visits for chronic illnesses. In 2012, the top four chronic diseases observed among Medicaid recipients in the service area (hypertension, diabetes and related conditions, asthma, and depression) affected 40% (240,984) of all Medicaid beneficiaries. Together, these four chronic conditions accounted for 148,724 hospital admissions and 235,111 ED visits. Diabetes and related disorders were responsible for the largest number of admissions (49,577 or 9.8%) and a significant percentage of total ED visits (8.8% or 53,890 visits). Of adult diabetes admissions, 1,944 were PQI admissions. Asthma was the number one ED diagnosis, responsible for 12.5% or 76,310 ED visits. Beneficiaries with asthma accounted for 31,666 admissions; in young adults, 569 admissions were classified as potentially avoidable, but this number is likely a vast underestimate. The fourth most common diagnosis among beneficiaries, depression, was found in 6.7% of ED visitors (40,966) and 5.1% among those admitted (25,891).

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NYS DOH DSRIP_Project Design Grant Application Section 3 Partner Organizations Service Area

3.3) Check off with a "X" of all the counties that are within your emerging Performing Provider System proposed service area.

Albany Herkimer Richmond (Staten Island)Allegany Jefferson Rockland

x Bronx Kings (Brooklyn) Saint LawrenceBroome Lewis SaratogaCattaraugus Livingston SchenectadyCayuga Madison SchoharieChautauqua Monroe SchuylerChemung Montgomery SenecaChenango Nassau SteubenClinton New York (Manhattan) SuffolkColumbia Niagara SullivanCortland Oneida TiogaDelaware Onondaga TompkinsDutchess Ontario UlsterErie Orange WarrenEssex Orleans WashingtonFranklin Oswego WayneFulton Otsego WestchesterGenesee Putnam WyomingGreene Queens YatesHamilton Rensselaer

Please type in the letter "X" OR you can use the drop down menu:

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NYS DOH DSRIP_Project Design Grant Application Section 4 Project Program Overview/Description

Project Program Overview

DSRIP Projects - Must choose a Minimum of 5, Maximum of 10:

Domain 2 - Must select 2 projects, Maximum of 4 - At least 1 from sub list A, and 1 from sub list B or C.Domain 3 - Must select 2 projects, Maximum of 4 - At least 1 from sub list A, and 1 from sub list A, B, C, D, E, F, G or H.Domain 4 - Must select 1 project, Maximum of 2 - At least 1 from sub list A, B, C or D.** Please see Appendix B in the Instructions for details of each Domain. For further information, see link below for the DSRIP Project Toolkit**

DSRIP Project Toolkit:

4.1)

Project #1- Sub-list A I.S.

2.A.I Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management 56

Project #2- Sub-list B or C I.S.

2.B.IV Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 43

Project #3 I.S.

2.A.III 46

Project #4 I.S.

2.C.I Development of community-based health navigation services 37

Provide reasoning regarding why your emerging Performing Provider System has selected the projects listed above from Domain 2 (Restricted to 4000 characters)

Characters used: 3967

4.2)

Project #1- Sub-list AI.S.

3.A.I Integration of primary care services and behavioral health 39

Project #2- Sub-list A - HI.S.

3.C.I Evidence-based strategies for disease management in high risk/affected populations (adults only) 30

https://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_project_toolkit.pdf

Domain 2 (System Transformation) - Applicants must select a minimum of two projects, maximum of 4 from this domain (one of which must be from sub-list A and one of which must be from sub-list B or C)

(REQUIRED) Must choose 1 from sub list A-->

(REQUIRED) Must choose 1 from sub list B or C-->

(NOT REQUIRED) Can choose 1 from sub list A, B or C-->

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.

(NOT REQUIRED) Can choose 1 from sub list A, B or C-->

The PPS selected four projects based on health outcomes and avoidable hospitalizations in the service area, the PAC’s priority project rankings (determined by a member survey), and the PPS’ ability to support project goals (assessed by 5-point Likert scale ratings). For all the projects chosen, DSRIP partners expressed high levels of confidence in their capabilities to proceed (average scale rating of 4.6). 2.a.i: Three neighborhoods consistently show poor health outcomes, contain the most Medicaid beneficiaries in the Bronx, and have the highest rates (per 100K people) of avoidable hospitalizations in NYC: Central Bronx (4,007), Highbridge-Morrisania (4,213), and Hunts Point-Mott Haven (4,310). Several partners have piloted successful projects to reduce hospital admissions by high-utilizing Medicaid patients. This PPS includes two of the most successful health homes, the Bronx Health Home and CCMP, together managing over 7,000 Medicaid lives in the Bronx. BLHC facilities have achieved NCQA PCMH Level 3 (2011) status and are pursuing Level 3 (2014) recognition. All PPS collaborators are committed to achieving Level 3 (2014) by DSRIP Year 2 and have the skills and determination to implement evidence-based practices throughout. 2.a.iii: PPS partners treat many patients inappropriate for Health Home under NYS standards, but who require higher levels of monitoring and coordination. Targeted patients have one chronic disease, but are at risk for more, particularly patients who have not yet needed hospitalization, but whose health/social status put them at high risk. BLHC has experience using the Patients-At-Risk-for-Rehospitalization (PARR) instrument to identify patients whose medical/social needs cannot be met in a PCMH, but do not qualify for Health Home services, and estimates that about 8% of patients will fall into this high-risk group. Care plans will be reviewed and patients will be triaged to more intensive management, as needed. Protocols will be created to screen for depression and other behavioral health co-morbidities, including substance use, utilizing the PHQ-9 depression scale and SBIRT. The PPS has plans to move forward this year with pilot projects to adapt NUKA team care to at-risk patients. Project 2.b.iv: There were 9,611 service area Medicaid PQI hospitalizations in 2012, 32% higher than expected. Highest numbers of Medicaid PQI hospital admissions occurred for COPD/Asthma in Older Adults (2,484), Heart Failure (1,385), and Diabetes Long-term Complications (1,098), representing 52% of all hospitalizations. Several PAC members have expertise in supporting transitions across various care settings, including BLHC, Dr. Martin Luther King, Jr. Health Center, VNS of NYC, Essen Medical Associates, and Urban Health Plan. BLHC participates in the Bronx Collaborative Care Transitions Program (based on the Coleman Chronic Care Model) that identifies patients at high-risk for readmission and implements strategies to reduce preventable admissions /readmissions. BLHC mental health services emphasize the adaptation of Project RED to mental health, with a discharge coach, read-back of discharge instructions, and phone follow-up using a CPEP Mobile Crisis Team. This effort will be expanded to substance abuse inpatient and housing providers. Project 2.c.i: Key service area health issues include obesity, diabetes, asthma, mental illness, substance abuse, and HIV. Many residents with these conditions do not have primary care physicians nor do they receive timely preventive/early intervention services. PPS partners serve a predominantly minority population with substantial barriers to care: poverty, lack of health insurance, and culture/language. Culturally competent peer navigators will engage high-risk Medicaid patients and be involved in their community life to reduce barriers, encourage healthy behaviors, and empower them to manage their own health, decreasing inappropriate acute care usage.

Domain 3 ( Clinical Improvement) – Applicants must select at least two projects from this domain (one of which must be A. Behavioral Health), but can submit up to 4 projects from Domain 3 for scoring purposes

(REQUIRED) Must choose 1 from sub list A-->

(REQUIRED) Must choose 1 from sub list A, B, C, D, E, F, G or H-->

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NYS DOH DSRIP_Project Design Grant Application Section 4 Project Program Overview/Description

Project #3- Sub-list A - H I.S.

3.D.II Expansion of asthma home-based self-management program 31

Project #4- Sub-list A - H I.S.

3.E.I 28

Provide reasoning regarding why your emerging Performing Provider System has selected the projects listed above from Domain 3 (Restricted to 4000 characters)

Characters used: 3741

4.3)

Project #1- Sub-list A-D I.S.

4.A.I Promote mental, emotional and behavioral (MEB) well-being in communities 23

Project #2- Sub-list A-D I.S.

4.D.I Reduce premature births 24

Provide reasoning regarding why your emerging Performing Provider System has selected the projects listed above from Domain 4 (Restricted to 4000 characters)

(NOT REQUIRED) Can choose 1 from sub list A, B, C, D, E, F, G or

H-->

(NOT REQUIRED) Can choose 1 from sub list A, B, C, D, E, F, G or

H-->Comprehensive Strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations – development of a

Center of Excellence for management of HIV/AIDS

The PPS selected 4 projects based on disease prevalence, PAC priority rankings, and the PPS’ ability to support project goals. 3.a.i: The PPS service area experiences a high prevalence of mental illness and substance abuse. Behavioral disorders due to drug overdoses are among the top 10 causes of death; 7.4% of residents report that they experience serious psychological distress. Collectively, 14 PPS partners are among the County’s top 50 Medicaid providers, serving 28,606 Medicaid members. Several PPS partners have adopted co-located primary care: BLHC, Dr. Martin Luther King, Jr. Health Center, Urban Health Plan, Essen Medical, AllMed, and others. BLHC is part of the DOH/OMH/OASAS joint licensing initiative. PPS partners have participated in HRSA and SAMHSA learning collaboratives around behavioral health integration. Dissemination of evidence-based practices (e.g., Project IMPACT, registries, linking primary care providers to care coordinators, and team case reviews) are proposed DSRIP projects. The goal is to move beyond coordination to a system of true integration. 3.c.i: Two PPS neighborhoods, Fordham-Bronx Park and South Bronx, have the highest diabetes prevalence rates in the State, 14.6% and 13.9%, respectively. Adult hospitalization rates for short-term complications of diabetes are higher in the Bronx than any other County. In the PPS service area, 61,217 adult Medicaid members (12%) have a diagnosis of diabetes; diabetes is the most frequent hospital admission diagnosis. BLHC, Dr. Martin Luther King, Jr. Health Center (MLK), Urban Health Plan, and Essen Medical Associates employ Certified Diabetes Educators. Others are piloting programs for patients with uncontrolled diabetes by providing intensive medication and self-management education. The PPS will expand these evidence-based initiatives throughout. 3.d.ii: The South Bronx has the highest prevalence of adults with asthma, representing 20% of NYC’s asthma cases; it also experiences the second highest use rates in NYC for asthma hospitalizations and ED visits. Asthma use rates are highest for young children. In the PPS service area, 56,462 Medicaid members (11%) had a diagnosis of asthma (2012). Asthma ranked number one in ED visits and third in hospital admissions among Medicaid members. Indoor and outdoor air quality is worse in the South Bronx than in other Bronx neighborhoods and NYC, and it contributes to exacerbation of asthma. The partner health homes, Bronx Health Home and CCMP, will assess asthma patients in their homes using trained care coordinators. Protocols will be established for examining the environment and for reviewing the asthma action plan, including medications at baseline, what should be added when moderate exacerbations occur, and what to do in emergencies. 3.e.i: In 2012, there were 629 new HIV cases and 464 new AIDS cases in the PPS service area; ~ 29,177 persons were living with HIV or AIDS (PLWHA), representing 25% of all PLWHA in NYC. Deaths from HIV totaled 440, representing 28% of all NYC deaths from HIV. Two percent of Medicaid members (11,978) had HIV disease in 2012; 3,699 (31%) were admitted to a hospital and 4,870 (41%) utilized a hospital ER. Several PPS partners provide specialty care and support services to a large number of Bronx residents with HIV/AIDS. BLHC and BOOM!Health together serve over 6,000 patients in practices that specialize in advanced HIV treatments. There remain, however, a large number of residents who are infected with HIV but have not been identified; or are identified, but not engaged or maintained in care. The PPS will disseminate guidelines around resistance testing and referral expectations, and provide telehealth consultation, when appropriate.

Domain 4 (Population-wide Strategy Implementation) – Applicants must select at least one project from this domain, but can submit up to 2 projects from Domain 4 for scoring purposes.

(REQUIRED) Must choose 1 from sub list A, B, C, or D-->

(NOT REQUIRED) Can choose 1 from sub list A, B, C, or D-->

The PPS selected 2 projects based on the service area demographics, community need, the PAC’s priority project rankings, and the PPS’ ability to support project goals. 4.a.i: In the Central and South Bronx, 35% of the population is < 18 years; 28% of residents have some high school education, but no diploma. The population is mostly minority (64% Hispanic, 35% Black); many residents do not speak English as their first language. All of these factors contribute to the higher prevalence of MEB illness far above national averages. Whereas 20% of youth nationally are affected by MEB disorders, the greatest unmet mental health service needs occur among racial/ethnic minorities, low-income, and uninsured persons. Suicide and attempted suicide rates among Latino adolescents are particularly troublesome. Early detection can decrease severity and chronicity of mental illness. Accordingly, the PAC made promotion of MEB health a priority. Toward this goal, the PAC seeks opportunities to connect medical and non-medical project partners. The PPS aims to promote MEB wellness activities in schools, housing agencies, social service organizations, youth groups, and public housing. It will engage community MEB providers to use evidence-based practices, consistent with Goal 1 of the NYS Prevention Agenda–promote MEB well-being in communities. A number of PPS collaborators provide MEB and supportive services for PPS service area residents in the community. Examples include the Icahn Charter School, which provides child mental health services for students at its Webster Avenue site. At Communilife’s Vida Clinic, residents ages 4 and older can receive outpatient mental health services, housing assistance, care coordination, case management, and meal assistance. The PPS will work with Dartmouth Psychiatric Research Center to develop community lifestyle interventions for residents with severe mental illness. The PPS seeks to expand the use of evidence-based practices and environmental strategies to facilitate MEB well-being as a service area priority. 4.d.i: The neighborhoods served by the PPS experience some of the highest premature birth rates in NYC and NYS, averaging 13.1% (2009-2011), compared to 12.0% (NYC),11.6% (NYS), and the NYS Prevention Agenda target (10.2%). Approximately 82% of childbirth costs are self-pay or paid by Medicaid. High rates of teen pregnancy/births, late or no prenatal care, and poverty are contributing factors. Teen birth rates in most PPS neighborhoods are among the highest in NYC. The percentage of pregnant women with late or no prenatal care (10.7%) is significantly higher than NYC (6.9%) and almost double the NYS rate (5.4%). Many PPS partners are experienced OB care providers. BLHC provides inpatient maternity services, overseeing 2,237 births in 2012, and is designated as a Level 3 perinatal center that includes a 14-bed NICU. Dr. Martin Luther King, Jr. Health Center, Urban Health Plan, Morris Heights Health Center, Community Healthcare Network, The Floating Hospital, HELP/PSI, Essen Medical Associates, Corinthian IPA, Amerigroup, East Tremont Medical Center, and Uptown Healthcare Management all provide prenatal and postpartum OB care. BLHC has implemented CenteringPregnancy®, an evidence-based group prenatal care model that will be disseminated. Many PPS partners provide WIC nutritional services. Morris Heights Health Center and BLHC are Healthy Families NY sponsors. PPS members have expressed interest in implementing home visiting programs to new mothers and their infants, such as the evidence-based Nurse-Family Partnership model, to reach more high-risk pregnant women who are not served by existing home visiting service delivery programs. All of these programs, and others, will be expanded by reaching out to the community to meet the challenge of reducing premature births.

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NYS DOH DSRIP_Project Design Grant Application Section 4 Project Program Overview/Description

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NYS DOH DSRIP_Project Design Grant Application Section 4 Project Program Overview/Description

Project Description

4.4)

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4.5)

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4.6)

Provide a brief executive summary of your emerging Performing Provider System's vision and goals and how your emerging Performing Provider System hopes to sustain these achievements beyond the DSRIP program timeframe. (Restricted to 3000 characters)

The PPS, led by Bronx-Lebanon Hospital Center (BLHC), aims to create a high-performing integrated delivery system focused on evidence-based medicine/population health management, with improved quality of care for more than 600,000 Medicaid beneficiaries in the South and Central Bronx. Consistent with the DSRIP goal to reduce avoidable hospital use by 25% over five years, the PPS will increase access to community-based integrated primary, specialty, behavioral health, and long-term care, as well as supportive services, through the collaboration of outpatient and other community providers. The PPS’ vision is to create a client-centered, value driven, and quality focused PPS, with payers and providers at the same planning table, measuring success by client engagement and its shared ability to deliver integrated services to meet client needs.

This level of system transformation marks a fundamental shift in health care delivery structures and mechanisms. PPS partners will help identify root causes and treatment gaps for the region by community needs assessment and community engagement during the planning period. The PPS will deftly respond to populations at risk with the sound infrastructure and operations necessary to provide innovative community-based preventive and early intervention services.

The PPS will sustain delivery system transformation beyond the waiver period by leveraging critical investments, made in DSRIP Years 1-5, in seven key areas: 1) Workforce development and human resources to increase the training, skills, diversity, and cultural competency of the multidisciplinary health and non-health workforce serving the target populations; 2) Collaboration linking providers, project collaborators, and regional stakeholders to strengthen the PPS organizational structure; to evolve deeper relationships leading beyond coordination to true integration; 3) Technology and tools to share relevant patient information quickly and efficiently through, for example, extending access to EHRs; 4) Project monitoring, through rapid cycle evaluation, to maintain emphasis on quality improvement, progress, and accountability for the structure and processes that will drive the system transformation; 5) Replication of evidence-based models that increase outpatient utilization of community-based services and sharing these best-practices for broader success in the PPS region; 6) Comprehensive, community-based health needs assessments that will involve the input of the community to continue effective population health management activities; and 7) Managed care payment reforms and good business practices making the PPS financially viable, with, better alignment of incentives through bundled payments for collaborative provider performance that improves patient outcomes and utilization and through risk sharing and capitation.

Why does your emerging Performing Provider System, as a whole, feel uniquely qualified to participate in DSRIP and serve the area you have proposed? (Restricted to 3000 characters)

Perhaps uniquely, the BLHC PPS grows from the community it will serve. The lead organization, BLHC, is completely committed—from the Board of Trustees to the CEO to the medical staff—to integration with its partners. A good example is the State-designated Bronx Health Home, initiated and led by BLHC. Excellent working relationships have been developed with over 70 health care and social services using a decentralized and inclusive approach that has included weekly conferences and the sharing of the BLHC care management capabilities through its Electronic Health Record (EHR). The Bronx Health Home keeps members informed, solicits frequent feedback, and provides efficient administrative systems so that each organization is paid for services in a timely fashion.

BLHC is using this same model in facilitating its PPS and PAC. To date, roughly 200 partners have confirmed their interest in participating in a PPS that will encompass the Central and South Bronx. A concerted effort was made to include providers across the spectrum of geography (i.e., 14 zip codes and five Bronx neighborhoods); patient populations (e.g., patients with disabilities, HIV/AIDS, and serious mental illness); and care settings (e.g., institutional and community-based). Current PPS partners represent the following provider types: a voluntary hospital, OMH, OASAS and OPWDD licensed providers, FQHCs, nursing homes, diagnostic and treatment centers, certified home health agencies, long-term home health care, supportive housing agencies, COBRA HIV/AIDS TCM and Targeted Case Management providers, primary care, managed care organizations, providers of individuals with intellectual and developmental disabilities, a correctional facility, independent practice associations, health information organizations, case management, health home, care management, and other community-based organizations. The proposed PPS collaborators are an effective group of providers dedicated to serving the Central and South Bronx and have the proven capacity to work out differences and achieve consensus on important issues.

Cultural competency is part of the core value system of each of the PPS partners. Together, the PPS partners serve a diverse population of some 870,000, covering more than one-half of the Bronx, consisting of Hispanic/Latinos, African Americans, and immigrants from the Dominican Republic and West Africa. They use similar strategies that include a culturally and ethnically diverse workforce, staff training, community outreach, consumer involvement in program planning and implementation, and multidisciplinary, multilingual care teams. By being visible in the community and acknowledging the diverse racial and ethnic mix of their clients in a culturally competent fashion, the PPS members have built a solid foundation of trust with individuals and community organizations.

What specific challenges does your emerging Performing Provider System foresee that could hinder the implementation of its DSRIP Project Plan? (Restricted to 3000 characters)

The PPS does not foresee any insurmountable challenges to implementing its DSRIP Project Plan. However, certain obstacles will require the expertise and concerted effort of the PPS partners to successfully achieve project goals.

• The PPS is a large collaboration of providers, with an even larger assortment of information technology capabilities. BLHC has been at the forefront of health information technology and has implemented Allscripts as its EHR at all its facilities, as has the Dr. Martin Luther King, Jr. Health Center, and is an active member of the Bronx RHIO. Many of the PPS FQHCs and medical groups have also implemented EHRs. The adoption of EHRs by individual physician practices and community-based agencies, however, is not as advanced. One of the PPS’ goals is to standardize IT capabilities across the provider network, as funds are available, so that patient information can be easily shared electronically and patient outcome data monitored. • The ability to obtain patient and population data at different geographic levels and across multiple years in a timely fashion is challenging. For DSRIP, patient and population data are needed to develop baseline metrics, conduct the community needs assessment, and assess outcomes. Although data availability has improved, the number of data sources needed to conduct these tasks is large and often unwieldy. • Recruiting staff to implement the various DSRIP projects will be an obstacle for some PPS partners and for some positions. Certain types of health care employees have been difficult to recruit in NYC in recent years, such as psychiatrists or psychiatric nurse practitioners. Seeking staff that are culturally competent and bilingual add to the challenge. To integrate primary care and behavioral health services, staff will need expertise in providing conjoint mental health and primary care. For staff that do not possess these skills, training will be required. As a group, the PPS has the resources to address this challenge. Organizations that have skilled employees that have worked in co-located settings can train staff that lack these skills.• Implementing changes in the service delivery model within the PPS collaborative will be impacted by each organization’s existing facilities. Co-locating behavioral health services at primary care sites, for example, may take more time to achieve if the facility lacks space for new staff. Primary care space is configured with several, small examination rooms; group space, required for some behavioral therapies and for interdisciplinary team meetings, is generally limited. PPS partners may need to reconfigure existing space, acquire additional adjacent space , move some functions offsite, or move to a new location• Finally, establishing governance among such a vast array of organizations will take determination and creativity. BLHC has faced daunting challenges previously, and will bring its experience and leadership abilities to the vanguard.

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NYS DOH DSRIP_Project Design Grant Application Section 4 Project Program Overview/Description

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The PPS does not foresee any insurmountable challenges to implementing its DSRIP Project Plan. However, certain obstacles will require the expertise and concerted effort of the PPS partners to successfully achieve project goals.

• The PPS is a large collaboration of providers, with an even larger assortment of information technology capabilities. BLHC has been at the forefront of health information technology and has implemented Allscripts as its EHR at all its facilities, as has the Dr. Martin Luther King, Jr. Health Center, and is an active member of the Bronx RHIO. Many of the PPS FQHCs and medical groups have also implemented EHRs. The adoption of EHRs by individual physician practices and community-based agencies, however, is not as advanced. One of the PPS’ goals is to standardize IT capabilities across the provider network, as funds are available, so that patient information can be easily shared electronically and patient outcome data monitored. • The ability to obtain patient and population data at different geographic levels and across multiple years in a timely fashion is challenging. For DSRIP, patient and population data are needed to develop baseline metrics, conduct the community needs assessment, and assess outcomes. Although data availability has improved, the number of data sources needed to conduct these tasks is large and often unwieldy. • Recruiting staff to implement the various DSRIP projects will be an obstacle for some PPS partners and for some positions. Certain types of health care employees have been difficult to recruit in NYC in recent years, such as psychiatrists or psychiatric nurse practitioners. Seeking staff that are culturally competent and bilingual add to the challenge. To integrate primary care and behavioral health services, staff will need expertise in providing conjoint mental health and primary care. For staff that do not possess these skills, training will be required. As a group, the PPS has the resources to address this challenge. Organizations that have skilled employees that have worked in co-located settings can train staff that lack these skills.• Implementing changes in the service delivery model within the PPS collaborative will be impacted by each organization’s existing facilities. Co-locating behavioral health services at primary care sites, for example, may take more time to achieve if the facility lacks space for new staff. Primary care space is configured with several, small examination rooms; group space, required for some behavioral therapies and for interdisciplinary team meetings, is generally limited. PPS partners may need to reconfigure existing space, acquire additional adjacent space , move some functions offsite, or move to a new location• Finally, establishing governance among such a vast array of organizations will take determination and creativity. BLHC has faced daunting challenges previously, and will bring its experience and leadership abilities to the vanguard.

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NYS DOH DSRIP_Project Design Grant Application Section 5 Community Needs Assessment

Community Needs Assessment

Examples of items to include in the descriptions can be found in the instructions.

Description

5.1)

Planning and Organizing

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Description - Each box is restricted to 5000 characters.

~ Keep in mind, the description box will expand as you type ~

members, PPS collaborators, stakeholders, representatives of the community (including minority and underserved consumers), community-based organizations, and patient advocacy groups, as well as delivery system representatives. As the planning period begins the individuals on this subcommittee will be responsible for oversight of the CNA effort and will report back to the PAC members. Additionally, this subcommittee will facilitate broad community engagement and will meet regularly throughout the CNA, advising on the process for stakeholder engagement, qualitative data gathering, and commenting on draft reports.

Because the CNA will have to inform final goal setting for the DSRIP Project Plan, final project, and PPS partner selection, Bronx-Lebanon will start preparing for the CNA work in July (before the design grant is awarded), plans to have intermediate results available by October 1st, and aims to finalize the DSRIP CNA report by November 15.

These preparation activities will include:• Developing a detailed work plan including milestones and decision points working, back from the deadline(s) with a detailed timeline• Determining governance of CNA, including role of PAC and relationship between PAC and subcommittees• Starting to identify the potential subcommittee members• Designing communication plans that outline overall communication within and between PPS partners, subcommittees, and the PAC • Creating timelines, budgets, and staffing plans for each activity in the work plan• Gathering existing information, such as previous CNAs written for the involved providers • Organizing access to required quantitative data• Organizing Stakeholder Engagement processes

KPMG will draft CNA goals for review by the PAC. Together, the PAC and KPMG will refine these goals, identifying tasks and a timeline. The preliminary goals include:

• Documenting the demographic characteristics and health needs of the population in the South and Central Bronx • Conducting a comprehensive assessment of the health care and community-based service resources currently available in the South and Central Bronx. This includes the current collective baseline performance Domain 2-4 DSRIP metrics and individual providers’ performance as can be measured during the CNA• Assessing what improvements in the PPS delivery system are required (based on, e.g., leading practices) to improve the value of care delivered by the population (specifically in terms of improvement in DSRIP metrics)• Understanding how existing resources can be leveraged by the emerging PPS to improve the health and well-being of the South and Central Bronx community• Ensuring that all necessary stakeholders are involved in the emerging PPS planning process and that the final programs address their perceived needs• Developing key community stakeholders’ buy-in as the PPS and DSRIP projects are developed

These goals may evolve over the course of the CNA process as information is gathered and new questions about the needs of the community emerge.

Our suggested timeline:

• 8/1/2014- Action: Create CNA Core Team.

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NYS DOH DSRIP_Project Design Grant Application Section 5 Community Needs Assessment

Description

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Description

Needs Assessment Methodology

3. Describe the baseline characteristics of the community (demographics and trends, epidemiological trends including risk factors and social determinants of health, insurance, current utilization patterns, disparities, current scores on domain 2-4 metrics), and compare to other communities (e.g., rest of the State at the most relevant level). Also, individual providers’ performance will be assessed as far as data availability allows.4. Establish geocoding system to map community resources using census block or other geographic units.5. Summarize data gathered in steps 1-4, sorted by project-related topic areas, for presentation to the PAC and key informants/stakeholders.

B. Elicitation from Community Stakeholders and Key Informants – Round 1 (Qualitative)6. Conduct focus groups and interviews with informants/stakeholders asking them to comment on the accuracy and completeness of the quantitative data summarized. In addition, ask them to respond to questions, such as: • What information is missing from the summary?• What do you see as the most immediate needs of the South and Central Bronx community? • Where are the service gaps in this community? (e.g., the availability, accessibility, affordability, acceptability, and quality of services, as well as the issues that influence utilization)• How can the PPS best meet these gaps? • How can connections among existing services and other resources be strengthened to ensure that a broad continuum of care is available?• What are your views on the DSRIP projects being considered by the PPS?

7. Summarize results of the focus groups and interviews by adding to the census lists, maps, and set of identified needs, and gaps. Identify new areas of information required to complete the CNA.

8. Report the results to the PAC and elicit reactions to the summarized information. Finalize the next set of CNA focus groups, interviews, and questions for the second round of elicitation.

9. Prepare summary documents for dissemination to community key informants and stakeholders for the second round of elicitation

C. Deepening of Quantitative Analysis using patient-level data10. As the qualitative elicitation (round 1) occurs, simultaneous analysis of patient-level datasets will occur to map patterns and outcomes of care across the service area, focusing on the areas where care utilization, as evidenced by admissions and ED visits, is the highest (using hot spotting, other geocoding techniques), and focusing on those project topics that are being identified as having the highest improvement potential overall11. Project current demographic and epidemiological trends forward 5-10 years, include projected goal attainment of current project selection, and analyze implications for future health system capabilities and capacity (e.g., beds, primary care professionals, etc.).

D. Elicitation from Community Stakeholders and Key Informants – Round 2 (Qualitative)12. Conduct a second round of interviews and focus groups to probe further and clarify the results of the first round and the results of the deeper quantitative analysis. Focus groups will be conducted with high-utilization patients (i.e., high Emergency Department users, multi-morbidity patients), to better understand their underlying reasons for high utilization. Share a brief a summary of PPS project plans and the rationale for programs selected. Elicit responses to the following questions:• What roadblocks do you anticipate in implementing these projects?

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NYS DOH DSRIP_Project Design Grant Application Section 5 Community Needs Assessment

5.3)

Data Collection

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Description

Stakeholders and other key informants will be invited to participate in several components of the CNA. These individuals will be identified through the census of community resources, guidance from members of the PAC, the CNA subcommittee, and recommendations from stakeholders interviewed (i.e. snowball sampling). We will include individuals who represent the broad spectrum of the health care system, community services, and other resources including health care providers, social service programs, a broad range of patient groups (including disabled populations), the correctional system, religious communities, unions, schools that train health care workers, representatives from new/large immigrant groups (e.g., Dominicans and West Africans) and organizations that serve them, Bronx community boards, housing programs and shelters, immigrant advocacy groups, legal aid, and employment services.

Three types of quantitative data will inform the CNA. First, baseline metrics data will be compiled and summarized by KPMG quantitative staff using existing databases. For the initial analysis of socio-demographic and epidemiological data, including broad determinants of health and health status, KPMG has identified sufficient available data sources. In addition, for those Domain 2-4 metrics that rely on Medicaid claims, SPARCS data, or other data sources that are primarily available to the State rather than to the PPS, the lead applicant assumes that DOH will publish these metrics at the zip code, county, and provider level (as relevant for the metric). DOH has announced a forthcoming Metrics Specification Guide, which will specify whether a metric is collected by the state or providers. A final data collection plan will be created when that guidance becomes available. For this plan, KPMG will also assess the capability to obtain PPS-wide medical record information as required by some of the DSRIP metrics.

Second, information on health care and community-based resources gathered through existing databases will be supplemented with data obtained through brief online surveys of these resources and other key community stakeholders. The survey questions will include topics as: 1. Socio-demographic characteristics and the health status of the population served2. Services provided and unmet population needs3. Entry points for clients or patients into a given program (how clients/patients find a program) and key referrals to outside PPS resources4. Names and contact information of possible key informants for interviews and focus groups

Third, depending on the State’s acceptance of the PPS’ data request, KPMG will analyze Medicaid and Medicare Anonymous Patient Level Data (APLD), allowing longitudinal analysis of the flow of patients throughout the whole care continuum, internal and external to the PPS. This is crucial for the PPS to investigate naturally occurring relationships between providers who ‘share’ patients in common, and deep-dive into where the gaps in services or quality delivered are found across the continuum of care. Also, this data will allow a more in-depth exploration of variations in practice patterns, and detailed hot spotting, and the analysis of drivers for suboptimal outcomes. Finally, having access to patient level data will allow for proper risk-adjustment, increasing the PPS’ ability to focus on where the real challenges lie. This information can help the PPS to target high-need geographic areas by linking them to available resources. The Medicare APLD data is important in this analysis, not only because utilization and spend is likely to be highest in the dually-eligible Medicare and Medicaid population, but also because much of the PPS planning will directly affect the Medicare population as well).

Qualitative data will be gathered through focus groups and in-person interviews with community stakeholders and key informants. They will be drawn from the full spectrum of community-based organizations, service providers, and health care services attending the needs of the South and Central Bronx. The CNA team will work with the PAC to determine which individuals will be interviewed in-person and which will be invited to participate in focus groups. The PPS anticipates that some focus groups will include participants representing a broad spectrum of resources (e.g. a focus group with individuals representing a variety of services or other resources from a specific neighborhood), while other focus groups will be comprised of individuals representing only one sector of the South and Central Bronx (e.g. a focus group of only case managers or only housing specialists drawn from across the region).

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NYS DOH DSRIP_Project Design Grant Application Section 5 Community Needs Assessment

5.4)

Reporting

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team will produce four summaries during the CNA: 1) the results of the resources census; 2) the initial compilation of quantitative data; 3) the results of the first elicitation; and 4) a summary of feedback from the second round of qualitative elicitation with the outcomes of the deeper quantitative analysis. The PAC and PAC subcommittees will be asked to review each report, provide their interpretation of the findings, and suggest additional questions to be answered as well as strategies to gather additional information in the subsequent CNA steps. In addition, the census and mapping information will be updated and included in each report.

The summaries of the baseline metrics data will include tables and graphics to illustrate comparisons by domain of the status of the South and Central Bronx (e.g. system metrics, clinical improvement metrics, health status, and disparities). Wherever possible, scores will be benchmarked to other zip codes/counties/regions, to the highest performing regions/providers, to NYC as a whole, to NYS, and to targets set by policy documents (e.g., the NYSDOH Prevention Agenda). Tables and figures will also illustrate the socio-demographic features of the service area population. Descriptive statistics will be employed as appropriate; advanced risk-adjustment and outcome measurement and provider attribution techniques will be used for the synthesis of the patient-level data. Narratives will accompany each set of tables to explain the findings and implications of these findings, such as comparisons by population groups. The results of the provider surveys will be summarized in tabular format with narrative explanations describing the findings and the implications of these findings for the PPS. Maps will show the distribution of services and other resources across the community; ‘value heat maps’ will indicate rates of health and social concerns by neighborhood. Tables, graphs, and maps will be developed to illustrate trends over time; this will become the foundation for the PPS reporting system to the community, showing the baseline, PPS goals, and the changes in these metrics on an annual basis.

For the purpose of project selection, KPMG will show PPS performance on all DSRIP metrics in relation to the average and the p10 percentile Statewide or national (or an alternative target set by DOH/CMS), both in terms of standard deviations and absolute percentage, following the latest available DOH guidance.

The reports of the qualitative findings will provide narrative description of responses to questions posed during the interviews and focus groups. In addition, results of key themes that emerge from the qualitative analyses will be summarized in each report. These themes will be interpreted in light of the quantitative data as appropriate.

All transcripts of interviews and focus groups conducted in Spanish will be translated to English for analysis. In addition, all reports will be translated into Spanish and excerpts of the reports will be written in both English and Spanish at a third grade reading level for dissemination community-wide.

The qualitative data collection process is designed to elicit stakeholder comments on summaries during the two rounds of elicitation; ongoing reporting back to these stakeholders of initial results is a core part of KPMG’s methodology. As described, the focus group and interview participants will be asked to comment on the information provided in the summaries as part of the interview or focus group: during the first Elicitation round community stakeholders and key informants will be actively engaged to reflect on the first two summaries (resources census and initial data compilation). In addition, these two summaries will also be posted on the PPS’ DSRIP web site after review by the PAC and CNA subcommittee. The public will have access to this web site and will be invited to leave comments or ask questions about the information summaries. After approval by the PAC and the CNA subcommittee, the latter two reports will similarly be made publicly available. These published reports and infographics will be presented as a prelude to fully interactive information (including heat-maps) for the public that will be made available during DSRIP year 1 by the PPS. Finally, the PPS communication plan will focus on eliciting the attention of the local press, and organizing community/town forums, as well as listening sessions to engage the community as widely as possible.

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NYS DOH DSRIP_Project Design Grant Application Section 5 Community Needs Assessment

Stakeholder Engagement

5.5) As an emerging Performing Provider System, please explain the process on how you plan to engage the key stakeholders to develop your DSRIP Project Plan? (Restricted to 3000 characters)

(Key stakeholders should not be a part of the emerging Performing Provider System) - See instructions for examples of key stakeholders

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Key stakeholders will be critical engagement partners during the three phases of DSRIP project planning, assessment, and project development. In phase 1—Organizing and Learning— the PAC, collaborating organizations, providers, and key stakeholders will be assembled to discuss shared goals for system transformation in the PPS service area. BLHC’s PPS is a diverse, multicultural, and unique array of key stakeholders, who provide health and non-health community-based services. The PPS anticipates working with other key stakeholders who like BronxWorks (a PPS member), provide housing, education, and social support services to individuals, families, and seniors, helping them to improve their mental, emotional, and behavioral well-being. Other key stakeholders will be solicited and invited to join PAC subcommittees (such as food programs, food pantries, and farmer’s markets; school-based partners, religious organizations, and advocacy groups). Many stakeholders have already joined BLHC’s PPS as PAC members, such as the Bronx RHIO and Urban Health Plan.

In phase 2—Assessment—the PPS will begin the comprehensive Community Needs Assessment (CNA) process to learn the demographics and health needs of the populations, as well as the health and community-based resources that are available in the region. The PPS, with the support of consultants, will engage stakeholders during all phases of the CNA (i.e., planning and organizing, collecting quantitative and qualitative data, and reporting), formally and informally, through interviews, focus groups, surveys, town hall meetings, and the publication of findings in print and on the web. One way to obtain and give feedback on information gleaned from the CNA will be through the Bronx Community Boards. PPS members have various relationships with the New York City Department of Health and Mental Hygiene. The PPS will utilize their rich datasets, as well as other data sources, to inform the CNA. Stakeholders have critical knowledge of the Medicaid and uninsured population in the service area and can help to interpret the CNA results and the social determinants (e.g., income, educational status, housing, behavioral risk factors, and policies) as well as the resource capacity and service gaps that lead to disparate health outcomes.

In phase 3—Project Development—the PPS will utilize the CNA results to identify projects based on the community and regional needs assessed. Key stakeholders will be asked to contribute to the DSRIP projects selected as members of the project subcommittees; their buy-in will be sought as DSRIP proposals are developed. The PPS anticipates working with Hostos Community College (CUNY), a stakeholder that has offered workforce development training using its expertise in curriculum development. The PAC will identify religious organizations, peer supports, and alternatives to incarceration to support PPS’ goals in the South and Central Bronx.

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NYS DOH DSRIP_Project Design Grant Application Section 6 List of Vendors

List of Vendors

6.1)

1 Organization Name KPMG LLP US, Healthcare Strategy and Operations 2 Organization Name To be determinedAddress City State Zip Code Address City State Zip Code

Organization Address 1676 International Drive, Suite 1200 McLean VA 22102 Organization AddressContact Person Marc Berg Contact Person

Contact Phone Number 703-286-2903 Extension: Contact Phone Number Extension:

Contact Email mberg1@kpmg.com Contact Email

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Address City State Zip Code Address City State Zip Code

Organization Address Organization AddressContact Person Contact Person

Contact Phone Number Extension: Contact Phone Number Extension:

Contact Email Contact Email

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Applicant must list contact information of any vendor they plan to contract with to assist in their DSRIP planning efforts. **The state maintains the right to approve any vendor used in the DSRIP program.**

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

KPMG is an expert in global health practice and has the industry leading experience to provide the following key activities during the planning period: project management and PPS performance management; developing PPS contractual arrangements, budget and funding distribution plans, dispute resolutions, and data agreement plans; practice recommendations and strategies for workforce development; performing macro and micro financial impact analyses; developing new business models with multi-payer reform strategies; and developing work groups and internal learning collaboratives. KPMG and Sarah McGraw, PhD (Research Resources) will collaboratively plan, conduct, and report on the quantitative and qualitative aspects of the Community Needs Assessment. Dr. McGraw brings over 25 years of experience as a Senior Researcher conducting large-scale community research analyses and evaluations.

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

The organization to be selected will have the experience and qualifications to provide web site design, development, hosting, and maintenance services during the planning period. The PPS DSRIP web site will house status updates and results of activities in the planning period phases. It will be accessible from the lead applicant’s main web site, but will have its own stand-alone web presence. The web site will serve as a tool to warehouse, archive, communicate, and disseminate key DSRIP information for the PPS service area to stakeholders, project partners, collaborators, and consumers. A key component of the web site will be the online forum to capture public comments. For members of the PAC, the web site will include private features to enhance DSRIP planning activities. The web site will be accessible across multiple platforms and devices, it will operate with audio visual capabilities, search functionality of archived content, and it will link to popular social media outlets.

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

The organization to be selected will provide communication and marketing for the PPS during the planning phase to engage consumers, stakeholders, project collaborators, and community-based physicians. Print and electronic methods will be used to catalogue participants’ contact information and to maintain a key list of supporters and invitees to DSRIP meetings, programs, events, and activities. This key support list will also be used to provide updates on DSRIP progress. The organization will have the expertise to lead communication and marketing campaigns for large-scale health-based networks This organization’s know-how will be critical facet of the stakeholder engagement plan throughout the planning phase.

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

Describe the vendor's

qualifications and how they will be

assisting the applicant in their planning efforts?

(Restricted to 1000 characters)

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NYS DOH DSRIP_Project Design Grant Application Section 7 Design Grant Timeline

Design Grant Timeline7.1)

Date (MM/DD/YYYY) Action/Decision/Milestone4/14/2014 Milestone DSRIP Year 0 begins

4/15/2014 Action4/21/2014 Action Drafted emerging PPS comments to State on MRT waiver amendment4/29/2014 Milestone Submitted public comments on MRT Waiver Amendment

5/2/2014 Action

5/6/2014 Action

5/15/2014 Milestone

5/21/2014 Action

5/30/2014 Action

6/4/2014 Action

6/11/2014 Action6/24/2014 Action Expert review of the DSRIP Planning Design Grant application prior to submission to the State.6/26/2014 Milestone Submitted the DSRIP Planning Design Grant application to the State.7/1/2014 Milestone The DSRIP planning phase begins.

7/8/2014 Action

7/15/2014 Action7/15/2014 Decision PAC, KPMG, and Dr. McGraw consensus on the initial CNA goals, tasks, and a timeline.

7/30/2014 Action8/1/2014 Milestone DSRIP Planning Grant awards are made from the State to the emerging PPS.

8/1/2014 Action

8/15/2014 Decision

8/15/2014 Action

Description (Up to 1200 characters)

Began emerging PPS communications and meetings with the lead applicant, project supporters, collaborators, stakeholders, community-based providers, and consumers to initiate the DSRIP planning phase.

Meeting: DSRIP kickoff meeting with the lead applicant, project supporters, collaborators, stakeholders, and community-based providers. An overview of DSRIP was provided to distill critical aspects of the planning, assessment, and project development phases. The benefits and challenges of borough-wide collaboration were discussed. An open group discussion of the implications and expected outcomes for the emerging PPS ensued. More than 100 participants were present.

Continued interaction and engagement activities to develop the Letter of Intent for the region of the South and Central Bronx including the Riker's Island facilities.

Submitted the Non-binding PPS Letter of Intent with the support of more than 80 health care and community-based organizations and 2 hospitals, 2 health homes, federally-qualified health centers, managed care organizations, care coordination entities, skilled nursing facilities, independent physician associations, private physician offices, behavioral health providers, home care agencies, housing agencies, and other key stakeholders.

Meeting: PAC meeting to establish the PAC roles, to review project domains and the project menu, to engage open discussion among PAC members, and to review the DSRIP timetable. Discussed innovative ways to continually ensure collaborator and stakeholder participation throughout DSRIP years 0-5.

Continued PAC interaction to make the potential DSRIP project selections. Each PAC member was asked to complete and submit a rank-order summary of their project selections along with a rationale for their selections. Continued work to summarize PAC vote results.

Meeting: PAC meeting to share results of PAC member votes on potential DSRIP project selections. Example project selections were displayed and group discussion ensued on how they could be implemented, their effect on the service area residents, how effectively they aligned with service area needs and also with service area priorities. Members began forecasting potential emerging PPS needs in aggregate that would be relevant for any DSRIP projects selected.

Continued PAC interaction with key stakeholders, consultants, and vendors to develop the DSRIP Planning Design Grant application.

Meeting: The PAC members will meet with the key Community Needs Assessment (CNA) consultants (i.e., KPMG, and Dr. Sarah McGraw) to refine the goals, identify tasks, and refine a timeline for the comprehensive CNA. This team meeting will include a discussion of the implementation plan of the CNA activities and processes. The PAC will setup and initiate the action of the 7 subcommittees for planning during the DSRIP grant period. The 7 subcommittees are: 1) Governance, 2) Strategic interventions, 3) Community needs assessment, 4) Workforce assessment, 5) Education and communication, 6) IT/Evaluation, and 7) Collaborative learning.

Face-to-face meetings and conference calls for the subcommittees to begin action. Subcommittees will discuss necessary components of the DSRIP Planning Design Grant application. Initial data requests made to State and or/vendors.

Establish a geocoding system to map community resources and population hotspots using census blocks or other geographic units of measurement.

Create the CNA core team to carryout the CNA goals, tasks, and adhere to the CNA timeline. The core team will complete the data collection, analysis, and summary activities. Leaders from KPMG and Dr. McGraw will direct the CNA core team activities. The team will begin the first round of CNA qualitative data collection through focus groups and interviews with community stakeholders and key informants.

The CNA workplan will be discussed for PAC approval. The workplan will include the definition of the PPS (e.g., geography, included population, and included providers).

Requested data obtained from State and or/vendors. Face-to-face meetings and conference calls for the subcommittees to develop the DSRIP Project Plan application components.

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NYS DOH DSRIP_Project Design Grant Application Section 7 Design Grant Timeline

8/20/2014 Action

8/21/2014 Action

8/21/2014 Decision

8/22/2014 Action

8/26/2014 Action

8/30/2014 Action

9/5/2014 Action

9/15/2014 Action

9/15/2014 Decision9/22/2014 Milestone Submit emerging PPS comments on draft DSRIP Project Plan application to the State.10/1/2014 Milestone The DSRIP implementation phase begins.

10/1/2014 Action

10/10/2014 DecisionPAC decision to move forward with the final selection of DSRIP projects informed by CNA results.

10/15/2014 Action

10/18/2014 Action

11/1/2014 Action

11/15/2014 Milestone

11/15/2014 Action

11/20/2014 Action

12/1/2014 ActionFace-to-face meetings and conference calls to continue work on the DSRIP Project Plan application draft #3.

12/9/2014 Action Expert review of the DSRIP Project Plan application prior to submission to the State.

12/10/2014 Action

12/10/2014 Decision12/16/2014 Milestone Submit the DSRIP Project Plan application to the State.

12/20/2014 ActionPlanned holiday break from DSRIP planning for PAC members, subcommittees, consultants, and vendors.

KPMG to begin CNA quantitative data collection (i.e., summary/census of community resources and quantitative data about the community including metrics data).

The findings from the first CNA qualitative data elicitation round will be summarized for initial PAC and stakeholder review to guide the questions and select participants for a second round of elicitation.

PAC, KPMG, and Dr. McGraw consensus with the CNA core team on the revised CNA goals, tasks, and a timeline.

Meeting: PAC review of DSRIP Project Plan necessary components created by subcommittees. Project summaries will be created for insertion in and alignment to the Official DSRIP Project Plan application (once released from the state). Any needed suggestions to subcommittees will be made at this time. Public comments to the newly released DSRIP Project Plan application from the State will be drafted. CNA qualitative results (from elicitation round #1) final reporting back to the PAC and subcommittees. Elicitation of PAC and subcommittee responses to summarized information.Summary of CNA qualitative results posted to PPS DSRIP web site for stakeholder and public review and comment.

The CNA core team will finalize the next set of CNA focus groups, interviews, and questions for the second elicitation round. The team will begin the second round of CNA qualitative data collection through focus groups and interviews.

Face-to-face meetings and conference calls for the subcommittees to develop the DSRIP Project Plan application draft #1.

Meeting: PAC review draft of the DSRIP Project Plan application draft #1 and to make suggestions to subcommittees.

The findings from the second CNA qualitative data elicitation round will be summarized for initial PAC review. Elicitation of PAC and subcommittee responses to summarized information. Comprehensive CNA interim results (Qualitative and Quantitative) discussed with the PAC and the subcommittees. Beginning discussions of possible final selections of DSRIP projects. Meeting: Presentation by the CNA subcommittee, KPMG, and Dr. McGraw to the PAC on how the CNA will continue throughout the implementation phase to provide ongoing feedback to the emerging PPS. Updated summary of CNA qualitative results posted to PPS DSRIP web site for stakeholder and public comment.

Establish elements of the CNA data collection systems that will continue into the implementation phase to provide on-going feedback for assessing program process and refining program components as population needs change.

The subcommittees will begin designing the implementation process, activities, and procedures. Face-to-face meetings and conference calls with stakeholders to discuss the preliminary outcomes of the comprehensive CNA (intermediate results). Face-to-face meetings and conference calls for the subcommittees to develop the DSRIP Project Plan application draft #2.

KPMG, Dr. McGraw, and the CNA core team will present preliminary report of outcomes of the comprehensive CNA to the PAC and the CNA subcommittee. Meeting: PAC meeting to review the DSRIP Project Plan application draft #2 content to be aligned with the Official DSRIP Project Plan application (once released from the state).

PAC and subcommittee review of the newly released DSRIP Project Plan applications posted to web and draft public comments to newly released DSRIP Project Plan application from the State.

Continued work on the DSRIP Project Plan application #2. Make sure that this draft aligns with the 10/18/2014 newly released DSRIP Project Plan application format and instructions.

DSRIP Year 0 comprehensive CNA results and summary report discussed and approved by the PAC and the CNA subcommittee.

Meeting: PAC and subcommittee review and gathering of all feedback for draft #3 of the DSRIP Project Plan application.

Reporting of CNA results to various stakeholders and posting of the comprehensive CNA summary report on the emerging PPS DSRIP web site. Invitation to community stakeholders and residents to review the CNA report and provide public comment.

Meeting: PAC joint roundtable review of the DSRIP Project Plan application draft #3. Final discussions of 2014 DSRIP assessment or implementation phase activities prior to close of the year.

All final decisions made for the DSRIP Project Plan application. Draft #3 has become the final document for submission. Routing the final DSRIP Project Plan application for approval by emerging PPS key leadership.

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NYS DOH DSRIP_Project Design Grant Application Section 7 Design Grant Timeline

1/2/2015 Action1/10/2015 Decision PAC decision to move forward with the final governance structure.

1/15/2015 Action2/1/2015 Action CURE period to review DOH and CMS comments on the DSRIP Project Plan application submitted.

2/10/2015 Action

3/1/2015 DecisionPAC decisions on the emerging PPS capital need requests to be requested from state and lending agencies.

3/2/2015 Action PAC development of capital needs proposals to state and lending agencies.

3/15/2015 Action3/15/2015 Milestone DSRIP Project Plan awards made.3/31/2015 Action PAC and subcommittee interactions and activities to prepare for DSRIP year 1.

Meeting: PAC meeting to review Governance subcommittee recommendations for the governance structure and to make public comments on the DSRIP Project Plan applications.

PAC and subcommittee telecommunication to create goals for implementation plans for IT infrastructure, protocols for reporting requirements, policies and procedures for payment, as well as the continued activities to ensure collaborator and stakeholder involvement.

PAC and subcommittee work during the CURE period to respond to DOH and CMS and provide clarification of responses and to address deficiencies. Meeting: PAC and subcommittee meeting to begin to assess capital needs, begin to address CNA results, recruit staff, and align staff training and resources to DSRIP project plans.

Meeting: PAC and subcommittee meeting to continue to address CNA results, recruit staff, and align staff training and resources to DSRIP project plans. Discussions of necessary components and preparations for DSRIP year 1.

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NYS DOH DSRIP_Project Design Grant Application Section 8 Data Request

Data Request

8.1) Please identify any additional data that would be helpful in completing your DSRIP Project Plan. For additional help, please see link below.

Type of Data Explanation of why this additional data will be helpful (Up to 1500 characters in each line)

Medicaid Beneficiaries, Inpatient Admissions, and Emergency Room Visits by Census Tract; Medicaid Chronic Conditions, Inpatient Admissions and Emergency Room Visits by Census Tract (Beginning 2012)

This data is needed for adequate Hotspotting analysis. It will enable the analysis of geographical clusters of high-cost patients, as zip code analyses do not provide enough detail. In order to adequately map health care needs and utilization in hotspots, plan the required provider capabilities, and organize capacity for high-need zones (by census tract), data with an additional level of geographical detail is needed.

Medicaid APLD (anonymous patient level data) (5 most recent years available, allowing linking of individual patients across the care continuum)

The Medicaid Anonymous Patient Level Data (APLD) will allow the linking of individual patients across the care continuum. It will allow the analysis of claims data at the patient level to establish population-based metrics, and to subsequently attribute the population-based health outcomes to PPS providers. This is a significant data need that will enable adequate PPS building. The emerging PPS will be able to investigate the naturally occurring provider relationships (between providers who share patients) by understanding the flow of patients in- and outside of the emerging PPS. Because patient outcomes are rarely the result of the static actions of an individual provider at one point, understanding the outcomes of care, the reasons behind poor outcomes, and how to improve these requires access to whole health care continuum longitudinal data sets. When this data is provided at a granular level, it will allow the PPS to engage in PPS-specific analytics, including a deeper exploration of variations in practice patterns, detailed hotspotting, and the analysis of the drivers for suboptimal outcomes. Finally, having access to patient level data will allow for proper risk-adjustment, increasing the focus on where the real challenges lie. APLD is preferred to preserve patient confidentiality under HIPAA regulations for PHI data. If necessary, a dataset in which the non-PPS providers are made anonymous with the provider type identified will be useful.

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NYS DOH DSRIP_Project Design Grant Application Section 8 Data Request

DSRIP Resources Link:See pages 87-92

Medicare APLD (anonymous patient level data) (5 most recent years available, allowing linking of individual patients across the care continuum, and, if possible, between Medicare and Medicaid)

The Medicare Anonymous Patient Level Data (APLD) will allow the linking of individual patients across the care continuum and between Medicare and Medicaid patients (if possible).This is needed because a significant proportion of Medicaid expenditures are linked to the dual beneficiary (Medicare and Medicaid eligible, or dual-eligible) population, a modest population by number, but representing a high share of total cost. Without access to the Medicare claims for duals, the validity of the analysis will be reduced as well as the ability of the PPS to create project plans that deliver the requested results. Additionally, many of the PPS projects selected will affect Medicaid, dual eligibles, and Medicare patients. To more efficiently grasp the overall project impacts and to optimally achieve the required targets, access to Medicare FFS data would be a significant value added. In terms of priority, the Duals Medicare data is essential to have; the non-Duals Medicare FFS data is very relevant, but less acutely essential. APLD is preferred to avoid HIPAA regulations, costs, risks, and barriers to analysis. If necessary, a dataset in which the non-PPS providers are made anonymous with the provider type identified will be useful.

Regional ethnography of service providers

The Community Needs Assessment (CNA) completed in DSRIP Year 0 will provide a static, cross-sectional view of the health care resources in the proposed PPS service area. What is needed, however, is a dynamic, continuously updated, virtual catalogue of the interdisciplinary health (e.g., primary, mental health, and behavioral health care providers, social service providers, and housing agencies) in the service area. In-depth qualitative methods of analysis could be used to capture this information. A key question to ask all providers and agencies would be how they could benefit from the DSRIP projects and plans that are being proposed for the service area. If the BLHC PPS had a critical understanding of how the providers and agencies would be affected by DSRIP projects, it could examine ways to enhance utilization of community-based primary, mental health, and behavioral health care, social services, and other non-medical support services for the residents in the service area.

https://www.health.ny.gov/health_care/medicaid/redesign/docs/waiver_amendment_update_present.pdf

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NYS DOH DSRIP_Project Design Grant Application Section 9 Design Grant Budget

Design Grant Budget9.1)

* Only include direct expenses related to developing your DSRIP Project Plan application.

Budget Cost Category Amount

Community Needs Assessment Costs:Contractors/Vendors $ 500,000 Data Analysis $ 250,000

Other:

Total Community Needs Assessment Costs: $ 750,000

Stakeholder Engagement Costs:Advertising $ 20,000 Website Design $ 40,000 Meeting Costs $ 20,000

Other:

Total Stakeholder Engagement Costs: $ 80,000

Application Development Costs:Other:

Total Application Development Costs: $ -

Other Category: Project Management1 FTE DSRIP Project Manager $ 140,000

Total $ 140,000

Other Category:

Total $ -

Grand Total $ 970,000

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NYS DOH DSRIP_Project Design Grant Application Section 9 Design Grant Budget

Capital Needs

9.2) Yes

If so, how much ? (Estimate): $ 63,895,000

If you selected 'Yes' or 'Maybe' in 9.2, please answer questions 9.3 and 9.4:

9.3)

Category Dollar Amount ($) Category Dollar Amount ($)Information Technology $ 2,667,000 Construction $ 34,785,000 Renovation $ 26,443,000

9.4)

Does your emerging Performing Provider System anticipate needing capital funding to achieve the goals of your DSRIP Project Plan?

Please use the grid to state which types of costs the capital funds would be utilized for (e.g. construction, renovation) as well as approximately how much funding would be needed for each potential category.

Please describe which DSRIP projects these capital funds would be applied to and how the capital funds will help the emerging Performing Provider System achieve its project specific DSRIP objectives. (Restricted to 3500 characters)The Bronx-Lebanon Hospital Center PPS, which has roughly 200 partners, has identified $63,895,000 in capital needs that apply to the following DSRIP projects:• 2.a.i. Create Integrated Delivery Systems that are focused on Evidence Based Medicine/ Population Health Management - $38,185,000 in capital funds is budgeted for new construction to house a Community Resource Center and field staff; renovations to expand primary care at existing clinic and public housing sites and provide psychiatric urgent care services; associated furniture and computer equipment for the new offices; HIT infrastructure expansion to connect the PPS sites; and care delivery platforms to support communications and information exchange in the integrated care delivery system. • 2.a.iii. Health Home At-Risk Intervention Program - $2,965,000 in capital funds is budgeted for renovations to establish primary care sites at assisted living facilities; provide additional conference, counseling and exam room space for care coordination; and establish psychiatric crisis respite beds, including associated office furnishings. Technology: purchase software to support risk stratification, data analysis, medication adherence, and care management.• 2.b.iv. Care transitions intervention model to reduce 30-day readmissions for chronic health conditions – $2,070,000 in capital funds is budgeted for: care management software to reduce 30-day readmissions and to support treatment planning and communications between providers.• 2.c.i. Development of community-based health navigation services - $315,000 in capital funds is budgeted for: expansion of primary care sites to provide space for health navigators, conference rooms, and day treatment programs; and technology to improve connectivity.• 3.a.i. Integration of primary care and behavioral health services - $16,360,000 in capital funds is budgeted for: renovations to expand primary care sites to include space for mental health providers, group meetings, and day treatment services; and add primary care satellites in behavioral health programs. Technology: computer modules for data aggregation, consent, and disease management; and to reconfigure configuration of technology. Office furnishings for new providers. • 3.c.i. Evidence based strategies for disease management in high-risk affected populations (adults only) - $2,075,000 in capital funds is budgeted for: renovations to create additional primary care exam rooms and expand diabetes centers; and purchase of computer software for disease management and treatment compliance. • 3.d.ii. Expansion of asthma home-based self-management program - $850,000 in capital funds is budgeted for: asthma disease management modules, telemedicine equipment for home-based follow-up and education; and environmental modifications for patients. • 3.e.i. Comprehensive strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations – development of a Center of Excellence for management of HIV/AIDS - $375,000 in capital funds is budgeted for renovations to create a telecommunications center, telemedicine equipment for specialist consultations, and surveillance software. • 4.a.i. Promote mental, emotional, and behavioral well-being in communities - $700,000 in capital funds is budgeted for renovations to create offices to provide mental health counseling and associated office furnishings.• 4.d.i. Reduce premature births in New York State – No capital funds are budgeted.

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NYS DOH DSRIP_Project Design Grant Application Section 9 Design Grant Budget

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

State of New York Department of Health

Delivery System Reform Incentive Payment (DSRIP) Program

** Please read instructions for ease of use **

1 2 3 4 5 6 7 8 9 10

Organization Name Address City State Zip Person Phone # Extension Email

1 Regeis Care Center YES 3200 Baychester Avenue Bronx NY 10475 Samuel Zeitman (718) 947-4669 samz@regeiscarecenter.com2 All Med and Rehabilitation of New York Yes 2604 Third Avenue Bronx NY 10454 Tony Martinez (914) 458-8114 tonymartinez001@aol.com3 APICHA Community Health Center Yes 400 Broadway New York NY 10013 Venus Vacharakitja, Director of (646) 744-2593 2593 Vvacharakitja@apicha.org4 ARGUS Community, Inc. Yes 760 East 160th Street Bronx NY 10456 James Schiller (718) 401-5733 jgschiller@arguscommunity.org5 ARMS ACRES, INC OUTPATIENT - BRONX YES 3584 Jerome Avenue Bronx NY 10467 ROY WALLACH (201) 236-8880 RWALLACH@LIBERTYMGT.COM6 Astor Services for Children and Families Yes 750 Tilden Avenue Bronx NY 10467 James McGuirk, Ph.D. 845-871-1000 jmcguirk@astorservices.org7 AstroCare, Inc. Health Care and Mental Services Yes 2510 Westchester Avenue Bronx NY 10461 Alan Weinstock (718) 559-0516 Alan.Weinstock@psch.org8 Bailey House Yes 1751 Park Avenue New York NY 10035 Jaymie Kahn 212-633-2500 470 jkahn@baileyhouse.org9 Bronx Park Nursing Center Yes 3845 Carpenter Ave Bronx NY 10467 Jeff Sicklick 718-798-1100 info@centershealthcare.com

10 Bronx Psychiatric Center No 1500 Waters Place Bronx NY 10461 Dr. Joseph Battaglia (718) 792-4178 joseph.battaglia@omh.ny.gov11 Bronx-Lebanon Hospital Center YES 1650 Grand Concourse Bronx NY 10457 Sam Shutman (718) 901-8920 sshutman@bronxleb.org12 Calvary Hospital and Hospice Yes 1740 Eastchester Rd Bronx NY 10461 Christopher Comfort, MD 718-518-2000 ccomfort@calvaryhospital.org13 Care for the Homeless YES 1605-11 Nelson Avenue Bronx NY 10453 DebbiAnn Fletcher (212) 366-4459 dfletcher@cfhnyc.org14 Casa Promesa Yes 308 East 175th Street Bronx NY 10457 Adrienne Rosell 718-960-7600 arosell@promesa.org15 Center for Urban Community Services Yes 665 Pelham Parkway Bronx NY 10467 Joe DeGenova (212) 801-3324 jdegenova@cucs.org16 Community Healthcare Network, Inc. YES 975 Westchester Avenue Bronx NY 10459 Elizabeth Howell (212) 545-2404 ehowell@chnnyc.org17 Comunilife Yes 4419 Third Avenue Bronx NY 10457 Dr. Rosa M. Gil (212) 219-1618 6141 rgil@comunilife.org18 Concourse Nursing and Rehab Center Yes 1072 Grand Concourse Bronx NY 10456 Dov Lebovic 718-681-4000 info@concourserehab.com19 Community Access Yes 2 Washington Street 9 floor New York NY 10004 Steve Coe 212-780-1400 7711 scoe@communityaccess.org20 Damian Family Care Center YES 138-02 Queens Blvd 2nd Fl. Briarwood NY 11435 Peter Grisafi (718) 657-1100 1225 pgrisafi@damianfcc.org21 Daughters of Jacob YES 1160 Teller Ave Bronx NY 10456 David Gamzeh (718) 293-1500 info@centershealthcare.com22 Daytop Village, Inc. Yes 2614-16 Halperin Avenue Bronx NY 10461 Steven Winston (212) 354-6000 swinston@daytop.org23 Dominican Sisters Family Health Service Inc. Yes 279 Alexander Avenue Bronx NY 10454 Mary Zagajeski (914) 772-5446 mjagajeski@dsfhs.org24 Dr. Martin Luther King Jr. Health Center, Inc. YES 1276 Fulton Avenue Bronx NY 10456 Lionel Stewart (718) 466-6072 lstewart@bronxleb.org25 Federation Employment and Guidance Service, Inc. Yes 3735 White Plains Road Bronx NY 10455 Kristin Woodlock (212) 366-8010 kwoodlock@fegs.org26 FEGS Home Attending Services, Inc. YES 424 East 147th Street Bronx NY 10455 Gabe Sofos (212) 491-6000 301 gsofos@fegshas.org27 Goodwill Industries of Greater New York and Northern New Jersey, Inc. YES 4-21 27th Ave Astoria NY 11102 Jenna Tine, LCSW (718) 777-6312 jtine@goodwillny.org28 Grand Manor Nursing Center Yes 700 White Plains Rd Bronx NY 10473 Anthony Restaino 718-518-8892 arestaino@grandmanor.org29 HELP/Project Samaritan Health Services, Inc. YES 1545 Inwood Avenue Bronx NY 10452 Sara Gillen (718) 681-8700 3264 sgillen@projectsamaritan.org30 Home Assistance Personnel Inc. Yes 2900 Exterior Street Bronx NY 10463 Audrey Weiner (718) 329-8389 aweiner@jewishhome.org

2.1) Partner Organizations - Contact Information General Provider Types

Fill out this form for the specific provider types we have listed in columns L & M

For all "Other" provider types, use the 2nd tab - Section 2.2_Partner Org_"Other".

SN Qualified (Y/N)

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

31 Housing Works, Inc Yes 1255 Rev. James Polite Ave Bronx NY 10459 Michael Clarke (347) 473-7475 clarke@housingworks.org32 Institute for Community Living YES 125 Broad Street - 3rd Floor NY NY 10004 David Woodlock (212) 385-3030 10001 dwoodlock@iclinc.net33 Jewish Association for Services for the Aged Yes 2705 Schley Avenue Bronx NY 10465 Danielle Palmisano (718) 863-8833 dpalmisano@jasa.org34 Jewish Board of Family and Children's Services Inc. Yes 55 Westchester Square Bronx NY 10463 Todd Schenk (212) 632-4776 tschenk@jbfcs.org35 Kings Harbor Multicare Center Yes 2000 East Gun Hill Road Bronx NY 10469 Alex Stern 718-320-0400 astern@kingsharbor.com36 Kingsbridge Heights Nursing Center Yes 3400 Cannon Place Bronx NY 10463 Bruce Zarett 718-796-8100 brucez949@aol.com37 Morris Heights Health Center Yes 57-69 West Burnside Ave Bronx NY 10453 Judith Fairweather 718-483-1207 8940 jfairweather@mhhc.org38 Narco Freedom, Inc Yes 479 Willis Avenue Bronx New York 10455 Madeline Perez (917) 645-0286 madeline.perez@narcofreedom.com39 Phoenix Houses of New York, Inc. YES 480 East 185th Street Bronx NY 10458 Dr. Steve Margolies (917) 572-4451 smargolies@phoenixhouse.org40 UCP Association of NYS Inc Y 979 Cross Bronx Expressway Bronx NY 10460 Duane Schielke (212) 356-1204 dschielke@cpofnys.org41 Postgraduate Center for Mental Health Yes 2330 Bronx Park East Bronx NY 10467 Marcia Holman (212) 889-5500 202 mholma@pgcmh.org42 Project Renewal Yes 200 Varick Street Bronx NY 10457 Kelly Beliveau (212) 620-0340 396 kelly.beliveau@projectrenewal.org43 PSCH, Inc. Yes 987-89 Prospect Ave Bronx NY 10459 John Kastan (347) 542-5626 john.kastan@psch.org44 Puerto Rican Family Institute Yes 4123 Third Avenue Bronx NY 10457 David Ortiz (212) 924-6320 dortiz@prfi.org45 Rebekah Rehab Yes 1070 Havemeyer Avenue Bronx NY 10462 Kenneth Gelb (718) 863-6200 kgelb@rebekahrehab.org46 Riverdale Mental Health Association YES 5676 Riverdale Ave Bronx NY 10471 Robert Brewster (718) 796-5300 rbrewster@rmha.org47 Samaritan Village Yes 1381 University Avenue Bronx NY 10452 Tino Hernandez (718) 206-2000 1222 thernandez@samvill.org48 Services for the Underserved Yes 1640 Macombs Road Bronx NY 10468 Donna Colonna (917) 408-1600 dcolonna@sus.org49 St. Vincent de Paul Residence Y 900 Intervale Avenue Bronx NY 10459 Richard Biscotti 917-645-9291 rbiscotti@archcare.org50 Steinway Child and Family Services, Inc. YES 22-15 43 Avenue, 2nd Floor Long Island City NY 11101 Pasquale DePetris, Ph.D. (718) 389-5100 110 pat.depetris@steinway.org51 Terrace Health Care Center Yes 2678 Kingsbridge Terrace Bronx NY 10463 Lowell Feldman (718) 796 - 5800 info@terrace-healthcare.com52 The Bridge Yes 416 East 138th Street Bronx NY 10459 Dr. Peter Beitchman (212) 663-3318 pbeitchman@thebridgeny.org53 The Floating Hospital, Inc. YES 285 East 171st Street Bronx NY 10457 Sean Granahan (718) 784-2240 sgranahan@thefloatinghospital.org54 The Mental Health Association of New York City, Inc. No 50 Broadway New York NY 10004 Kathryn Salisbury (212) 254-0333 796 ksalisbury@mhaofnyc.org55 Unique People Services No 4234 Vireo Avenue Bronx NY 10470 Yvette B. Andre (917) 586-0783 yvetteba@uniquepeopleservices.org56 University Consultation and Treatment Center for Mental Hygiene No 1020 Grand Concourse Bronx NY 10451 Marcia Halley (718) 293-8400 217 mhalley@universityconsultationcente57 University Nursing Center Yes 2505 Grand Avenue Bronx NY 10468 David Gamzeh 718-295-1400 info@centershealthcare.com58 Urban Health Plan Yes 1065 Southern Blvd Bronx NY 10459 Paloma Hernandez 718-589-2440 paloma.hernandez@urbanhealthplan.59 VillageCare Home Care Yes 154 Christopher Street NY NY 10014 Jean Pierre Burke (212) 337-5775 jeanb@villagecare.org60 Visiting Nurse Service of New York Home Care YES 1250 Broadway, 4th floor New York NY 10001 Sarah Larson 212-609-7563 sarah.larson@vnsny.org61 Vocational Instruction Project Community Services, Inc. YES 1910 Arthur Ave Bronx NY 10457 Debbie Pantin (718) 466-8810 8810 dpantin@vipservices.org62 Weston United Community Renewal No 3130 Villa Avenue Bronx NY 10458 Jean Newburg (212) 866-6040 jnewburg@westonunited.org63 Williamsbridge Manor Yes 1540 Tomlinson Avenue Bronx NY 10461 David Gamzeh 718-892-6600 info@centershealthcare.com64 Woodycrest Center for Human Development Yes 153 West 165th Street Bronx NY 10452 William Cohen (718) 293-3200 wcohen@highbridgewoodycrest.org65 Bronx Child and Family Mental Health Center YES 358 East 149th Street Bronx NY 10455 Eric B. Bettelheim, J.D. 917-861-6362 EricBettelheim@nypcc.org66 Bronx Lebanon Integrated Services System, Inc. YES 1650 Selwyn Avenue, Apt 11H Bronx NY 10457 Saudah Muhammad 718-466-8163 SMUHAMMA@bronxleb.org67 Harlem United / URAM YES 306 Lenox Avenue, 3rd Floor New York NY 10027 Jacqui Kilmer 212-803-2850 jkilmer@harlemunited.org68 Jewish Home Lifecare’s Bronx campus YES 100 West Kingsbridge Bronx NY 10468 Rita Morgan 718-410-1526 rmorgan@jewishhome.org.69 Center for Alternative Sentencing & Employment Services, Inc. (CASES) Yes 346 Broadway, 3rd Floor West New York NY 10013 Joel Copperman 212-553-5301 jcopperman@cases.org70 Morningside House Nursing Home Company, Inc. Yes 1000 Pelham Parkway Bronx NY 10461 Dr. William T. Smith 718-409-8200 wsmith@aiamsh.org71 SUS-Developmental Disabilities Services, Inc Y 305 7th Ave, 10th Floor New York NY 10001 Donna Colonna (917) 408-1600 dcolonna@sus.org72 Lifespire Y 1 Whitehall, 9th Floor New York NY 10004 Oonagh Christie (212) 741-0100 569 ochristie@lifespire.org73 Lifespire - SPAN Mental Health Clinic Y 184-10 Jamaica Avenue Hollis NY 11423 Oonagh Christie (212) 741-0100 569 ochristie@lifespire.org74 HeartShare Wellness LTD. Y 177 Livingston Street New York NY 11201 Jude Alexandre (718) 857-7707 8018 jude.alexandre@heartshare.org75 Premier HealthCare - 34th Street Manhattan YES 406 10th Avenue, 9th Floor New York NY 10001 Navneet Kathuria 2122736381 navneet.kathuria@yai.org76 Premier HealthCare - East Tremont YES 3060 East Tremont Avenue, 2nd FlooBronx NY 10461 Navneet Kathuria 2122736381 navneet.kathuria@yai.org77 Premier HealthCare - Nostrand YES 3364 Nostrand Avenue Brooklyn NY 11361 Navneet Kathuria 2122736381 navneet.kathuria@yai.org78 Premier HealthCare - Bayside YES 211-11 Northern Boulvard, 2nd FloorBayside NY 11361 Navneet Kathuria 2122736381 1021 navneet.kathuria@yai.org79 Premier HealthCare - Remsen Street YES 175 Remsen Street, 4th Floor Brooklyn NY 11201 Navneet Kathuria 2122736381 navneet.kathuria@yai.org80 Premier HealthCare - Astoria YES 37-11 35th Avenue Astoria NY 11101 Navneet Kathuria 2122736381 navneet.kathuria@yai.org81 UCP Association of NYS Inc Y 2324 Forest Avenue Staten Island NY 10303 Duane Schielke (212) 356-1204 dschielke@cpofnys.org82 UCP Association of NYS Inc Y 51-40 59th Street Woodside NY 11377 Duane Schielke (212) 356-1204 dschielke@cpofnys.org83 UCP Association of NYS Inc Y 921 East New York Avenue Brooklyn NY 11203 Duane Schielke (212) 356-1204 dschielke@cpofnys.org84 The PAC Program YES 1215-1217 Strafford Ave Bronx NY 10472 Lawrence Lang 718-382-2605 Lawrence@thepacprogram.com

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

85 Palladia Inc. YES 1366 Inwood Ave Bronx NY 10454 Susan Wiviot 212-979-8800 susan.wiviot@palladiainc.org86 Rivington House YES 45 Rivington House New York NY 10002 Ingrid Jimenez 212-337-5930 ingridj@villagecare.org87 Village Diagnostic and Treatment Center Yes 121A West 20 Street New York NY 10011 Ingrid Jimenez 212-337-5930 ingridj@villagecare.org88 Workmen's Circle MultiCare Center YES 3155 Grace Avenue Bronx NY 10469 Soloman Rutenberg 718-379-8100 440 srutenberg@wcmcc.org89 Empire State Home Care Services Y 205 Lexington Avenue (3rd Floor) c/ New York NY 10016 Laura Page-Greifinger 718-923-7134 Laura2PG@msn.com90 Terence Cardinal Cooke Health Care Center Y 1249 Fifth Avenue New York NY 10029 Neil Pollack 212-360-3999 npollack@archcare.org91 Calvary Home Care N 1740 Eastchester Road Bronx NY 10461 David Grayson 718-518-2244 david@graysonandco.com92 St. Vincent de Paul Residence Y 900 Intervale Avenue Bronx NY 10459 Richard Biscotti 917-645-9291 rbiscotti@archcare.org93 Alpine Home Care YES 4260 Bronx Blvd Bronx NY 10466 Deborah Forbes, RN 914-323-8769 dforbes@alphhc.org94 HELP/PSI Services Corp Yes 1543-1545 Inwood Avenue Bronx New York 10452 Sara Gillen 718.681.8700 3264 sgillen@projectsamaritan.org95 HELP/PSI Services Corp Yes 226 E. 144th Street Bronx New York 10451 Sara Gillen 718.681.8700 3264 sgillen@projectsamaritan.org96 HELP/PSI Inc. Yes 1543-1545 Inwood Avenue Bronx New York 10452 Sara Gillen 718.681.8700 3264 sgillen@projectsamaritan.org97 HELP/PSI Inc. Yes 1401 University Avenue Bronx New York 10452 Sara Gillen 718.681.8700 3264 sgillen@projectsamaritan.org98 ADDICTION RESEARCH AND TREATMENT CORPORATION YES 22 Chapel Street Brooklyn NY 11201 Charles Madray 718-260-2968 CMADRAY@artcny.org99 Damon House, Inc YES 310 south 1st st Brooklyn NY 11211 Dr. Janet Lerner 718-443-7170 janlern@aol.com

100 EXCELLENT HOME HEALTH CARE yes 305 Berry Street Brooklyn NY 12111 Moshe Neuman 718-387-1800 info@ehcny.org101 Fortune Society YES 26-76 Northern Blvd, 2nd Fl Long Island City NY 11101 Stanely Richards 212-691-7554 srichards@fortunesociety.org102 NEW ALTERNATIVES FOR CHILDREN, INC. (NAC) YES 37 West 37th Street New York NY 10010 Wendy Geringer, Ph.D 646-352-9076 wgeringer@nackidscan.org103 NEW FOCUS CENTER YES 70 Ashburton Avenue 5th Floor Yonkers NY 10701 Ron Corti 914-964-8000 info@riversidehealth.org104 SELFHELP SPECIAL FAMILY HOME CARE INC YES 520 Eighth Avenue New York NY 10018 Stuart Kaplan 212.971.7723105 St. Joseph's Hospital, Yonkers YES 127 South Broadway Yonkers NY 10701 Michael J. Spicer 914-378-7485 michael.spicer@saintjosephs.org106 YES 845 Palmer Avenue Mamaroneck NY 10453 Audrey Weiner 212-870-4603 aweiner@jewishhome.org107 ST.CHRISTOPHER'S INN YES 21 Franciscan Way Garrison NY 10524 David Gerber 845-335-1101 dgerber@atonementfriars.org108 THE EPILEPSY INSTITUTE YES 257 Park Ave. South, Suite 302 New York NY 10021 PAMELA CONFORD (212) 677 - 8550 pconford@efmny.org109 Conifer Park YES 79 Glenridge Road Glenville NY 12302 Roy Wallach 800-989-6446 92 rwallach@libertymgt.com110 Odyssey House, Inc. YES 95 Pine St, 17th Fl, New York, NY New York NY 10005 Daryl Everett 212-361-1678 deverett@odysseyhouseinc.org111 SKIP YES 601 west 26 street, 5th floor suite 5 New York NY 10001 Marguerite Mikol 212-268-5999 mmikol@skipofny.org112 Abbott House YES 100 North Broadway Irvington NY 10533 (914) 591-7300 info@abbotthouse.net113 AABR, Inc. YES 1508 College Point Blvd College Point NY 11356 MR. MARK ANDREW SOBIESKI SR718-321-3800 mark@aabr.org114 QSAC, Inc. YES St. Albans NY 11411 GARY MAFFEI 212-244-5560 gmaffei@qsac.com115 Advocates for Services for the Blind Multihandicapped, Inc. YES 3106 Coney Island Ave Brooklyn NY 11235 Mary Pyle MPyle@asbm.org116 LOWER EASTSIDE SERVICE CENTER, INC. YES 80 Maiden Lane New York NY 10010 Lolita Silva-Vasquez 212-566-7712 lsilvavasquez@lesc.org117 Saint Dominic's Home YES 500 Western Hwy Blauvelt NY 10913 Judith D. Kydon 845-359-3400 201 Jkydon@Sdomhome.org118 Cardinal McCloskey Community Services YES 115 E Stevens Ave, Suite LL5 Valhalla NY 10595 Beth Finnerty (914) 997-8000 bfinnerty@cmcs.org119 Human First, Inc. YES 128 Atlantic Avenue Lynbrook NY 11563 Wafa Abboud 516-823-9500 wabboud@humanfirst.us120 SLCD/ Able Community Services NO 100 Glen Cove Avenue Glen Cove NY 11542 Teresa Dunckley tdunckley@slcd.org121 Catholic Guardian Society and Home Bureau YES 1011 First Avenue New York NY 10022 2300 clongley@catholicguardian.org.122 Independence Residences, Inc. YES 9416 Jamaica Ave Woodhaven NY 11421 Raymond DeNatale (718) 805-6796 rdenatale@in-res.org123 SCO Family of Services YES 1 Alexander Place Glen Cove NY 11542 Gail B. Nayowith (516)671-1253 gnayowith@sco.org124 Community Resource Center for the Dev. Dis., Inc. YES 378 East 151st Street 4th floor Bronx NY 10455 Mr. Kevin Meade 718-292-1705 kmeade@crcdd.org125 The Center for Family Support YES Bronx NY 10461 Steven Vernikoff 212.629.7939 svernikoff@cfsny.org126 ARMS ACRES, INC OUTPATEINT - QUEENS YES 80-02 Kew Gardens Road Kew Gardens NY 11415 ROY WALLACH 201-236-8880 RWALLACH@LIBERTYMGT.COM127 The Shield Institute YES 144-61 Roosevelt Ave New York NY 11354 Dr. Susan Provenzano 718-939-8700 sprovenzano@shield.org128 BRC YES 131 West 25th Street, 12th Floor New York NY 10001 Muzzy Rosenblatt 212-803-5700 muzzy@brc.org129 Leake & Watts Services, Inc. YES 463 Hawthorne Ave Yonkers NY 10705 Alan Mucatel amucatel@leakeandwatts.org130 Episcopal Social Services YES New York NY 10001 Elizabeth McCarthy 212-675-1000 mccarthye@e-s-s.org131 Little Flower Children and Family Services of NY YES 186 Joralemon St Brooklyn NY 11201 Grace G. Lo Grande 718-875-3500 lograndg@lfchild.org132 Brooklyn AIDS Task Force YES 502 Bergen St Broooklyn NY 11217 Gasner Garcon 347-505-5112 Ggarcon@BATF.net133 NY Foundling YES New York NY 10011 Bill Baccaglini bill.baccaglini@nyfoundling.org134135136137138

skaplan@selfhelp.net

SARAH NEUMAN CENTER FOR HEALTHCARE & REHABILITATION .

JAMES L. KAUFMAN, LCSW-R,

11860 Springfield Blvd 718-934-2592

516-609-2000Craig Longley (212) 371-1000

2811 Zulette Avenue

914.375.8700 305 7th Ave 4th Floor

590 Avenue Of The Americas (212) 633-9300

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398399400401402403404405406407408

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

517518519520521522523524525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562563564565566567568569570

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

571572573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618619620621622623624

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

625626627628629630631632633634635636637638639640641642643644645646647648649650651652653654655656657658659660661662663664665666667668669670671672673674675676677678

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

679680681682683684685686687688689690691692693694695696697698699700701702703704705706707708709710711712713714715716717718719720721722723724725726727728729730731732

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

733734735736737738739740741742743744745746747748749750751752753754755756757758759760761762763764765766767768769770771772773774775776777778779780781782783784785786

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

787788789790791792793794795796797798799800801802803804805806807808809810811812813814815816817818819820821822823824825826827828829830831832833834835836837838839840

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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100010011002

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

121912201221122212231224122512261227122812291230123112321233123412351236123712381239124012411242124312441245124612471248124912501251125212531254125512561257125812591260126112621263126412651266126712681269127012711272

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

154315441545154615471548154915501551155215531554155515561557155815591560156115621563156415651566156715681569157015711572157315741575157615771578157915801581158215831584158515861587158815891590159115921593159415951596

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

181318141815181618171818181918201821182218231824182518261827182818291830183118321833183418351836183718381839184018411842184318441845184618471848184918501851185218531854185518561857185818591860186118621863186418651866

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

186718681869187018711872187318741875187618771878187918801881188218831884188518861887188818891890189118921893189418951896189718981899190019011902190319041905190619071908190919101911191219131914191519161917191819191920

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

Assisted Living Facility OASAS (Article 32) Provider

OMH (Article 31) Provider

Critical Access Hospital (CAH) OPWDD (Article 16) provider

Public Hospital

Skilled Nursing Facility

Nursing Home

"OTHER" Providers - Fill out Section 2.2 11 12 13 15 16

Provider Type MMIS OPCERT NPI #1 NPI #2

Skilled Nursing Facility 315031 7000356N 1386623874 NADiagnostic & Treatment Center (Non FQHC) 2100810 7000259R 1902008402Federally Qualified Healthcare Center (FQHC) 2997175 7002173R 1730303017OMH (Article 31) Provider 1370850 7922300B 1659412849 1932241429OASAS article 822.4 OUTPATEINT 3008211 170511619 1649474552OMH (Article 31) Provider 2994769 18320 1255433835 1225009806OMH (Article 31) Provider 2648084 44400 1427074574OMH (Article 31) Provider 2822911 8124001A 1083820583Nursing Home 309628 7000380N 1003988619OMH (Article 31) Provider 1137237 73910 1639475510Voluntary Hospital (Non CAH, Non Sole Community Provider476022 7000001H 1417027558Voluntary Hospital (Non CAH, Non Sole Community Provider2023403 7000011H 1932127172Federally Qualified Healthcare Center (FQHC) 3064422 7000279R 1952647430Nursing Home 1547355 7000373N 1801833652OMH (Article 31) Provider 2993837 7964475A 1053408211 1871926782Federally Qualified Healthcare Center (FQHC) 695941 7002119R 1477764496OMH (Article 31) Provider 1526329 10310 1528082013Nursing Home 335493 7000375 1467457002OMH (Article 31) Provider 1303355 7422017A 1295046225 1700085719Diagnostic & Treatment Center (Non FQHC) 1690633 7003246R 1508955592Nursing Home 310325 7000342N 1194727156Diagnostic & Treatment Center (Non FQHC) 659687 700212R 1205957297Long Term Home Health Care Provider 1136130 5905901L 1104902949Federally Qualified Healthcare Center (FQHC) 244573 7000212R 1619275039OMH (Article 31) Provider 1371571 40480 1912164120 1699714618Certified Home Health Agency 922270 9659L001 1619047131 1912164120Not-for-profit PROS/Clubhouse 2997340 6329003A 1801080478Nursing Home 358021 7000361N 1588667125Federally Qualified Healthcare Center (FQHC) 2958212 7000277R 1003093436Long Term Home Health Care Provider n/a 7000902 1285777243

Provider Type: ONLY choose from the following:

Certified Home Health Agency

Diagnostic & Treatment Center (Non FQHC)

Federally Qualified Healthcare Center (FQHC)

Long Term Home Health Care Provider

Sole Community Provider (SCP)

Voluntary Hospital (Non CAH, Non Sole Community Provider)

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Diagnostic & Treatment Center (Non FQHC) 1350509 n/a 1538379573OMH (Article 31) Provider 1305004 7720440 1558494930OMH (Article 31) Provider 848614 19000 1861570517OMH (Article 31) Provider 2996918 6709103A 1821273459 14689755662Nursing Home 310292 7000372N 1952395626Nursing Home 309742 7000374N 1104968189Federally Qualified Health Center (FQHC) 590390 700236R 1184694291 1265651020Diagnostic & Treatment Center 245107 7000227R 1174562003OASIS (Article 32) Provider 2644448 160110035 1134297153Diagnostic & Treatment Center (Non FQHC) 3006273 7002126R 1366507758OMH (Article 31) Provider 244257 6728100A 1629127725 1801945365Diagnostic & Treatment Center (Non FQHC) 1572361 7002161R 1598770018OMH (Article 31) Provider 1304109 21920 1508012816OMH (Article 31) Provider 1424217 40450 162905515Long Term Home Health Care Provider 309366 7000914 1114276292OMH (Article 31) Provider n/a 6733300A 1558380501Diagnostic & Treatment Center (Non FQHC) 2718096 703220R 1548347719OMH (Article 31) Provider 1304338 7320472a; 7320006a1881816643 1053696195Assisted Living Facility 03547651 020-E-133 1053390534OMH (Article 31) Provider 245074 6749120A 1801844584 1053568329Nursing Home 308205 7000378N 1780681874OMH (Article 31) Provider 2997244 18130 1831269315Federally Qualified Healthcare Center (FQHC) 245038 7002289R 1306954631OMH (Article 31) Provider 3421029 7957018A 1013230374OPWDD (Article 16) provider 1354214 1354214 1861616518OMH (Article 31) Provider 244775 6743430 1750444188Nursing Home 312249 7000337N 1811005010Federally Qualified Health Center (FQHC) 2994952 7000225R 1265596548Certified Home Health Agency 2578958 7002657 1932128386Certified Home Health Agency 02996041 (cluster); 7002655 1528059805OASAS Article 32 Provider 828919 140510366 1881733830OMH (Article 31) Provider 2187286 7646431 1821263633 1225202708Nursing Home 312478 7000379N 1912931833Nursing Home 335751 7000363 1598857203OMH (Article 31) Provider 245056 15450 1902811342Federally Qualified Healthcare Center (FQHC) not applicable not applicable not applicableFederally Qualified Healthcare Center (FQHC) 1741726 7002153R 1417986340Skilled Nursing Facility 335462 7000317N 1912072208OMH (Article 31) Provider 2770125 8908004A 1932523438 1922165117Nursing Home 309820 7000345N 1336118892OPWDD (Article 16) provider 2005392 7559000 1619140241OPWDD (Article 16) provider 1500150 6136-000OMH (Article 31) Provider 347755 7526-100A 1164629788Diagnostic & Treatment Center (Non FQHC) 2087016 7001294R 1326092396 1487895371Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 1751000 7002154R 1760436190Diagnostic & Treatment Center (Non FQHC) 3006282 7002126R 1376600551Diagnostic & Treatment Center (Non FQHC) 3006255 7002126R 1255496642Diagnostic & Treatment Center (Non FQHC) 3006282 7002126R 1285799684OASAS Article 32 Provider n/a 100411691 1497981328

1356770192

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OASAS Article 32 Provider 3007605 150810950 1093883720 1710055827Nursing Home 1552056 7002353N 1609874585Diagnostic & Treatment Center (Non FQHC) 2743557 7002181R 1457424863Nursing Home 311000 7000390N 1003970559Certified Home Health Agency 02317499 7001633 1801993753OPWDD Article 16 Provider 03001829 6660100 1215100458Certified Home Health Agency 03000039 7000608 1417968488Skilled Nursing Facility 02993819 7000366N 1053390534Certified Home Health Agency 890813 7000609 1912179763OMH (Article 31) Provider 2952812 8130001A 1003093436Federally Qualified Healthcare Center (FQHC) 2952812 7000277R 1003093436Diagnostic & Treatment Center (Non FQHC): HIV ADHC 2995339 7000362N 1346464989Skilled Nursing Facility 2995339 7000362N 1346464989OASAS (Article 32) Provider 244606 7001214R 1952342115OASAS (Article 32) Provider n 1024 1154669661Certified Home Health Agency 337424 7001634 1881708642OMH (Article 31) Provider 2740141 8095001A 1235357237OMH (Article 31) Provider 2938925 20570 1730339128OASAS (Article 32) Provider 245501 87150 1578526695Certified Home Health Agency 1559026 7002651 1477556199OASAS (Article 32) Provider 258920 81050 1619032273Nursing Home 1266233 5909302N 1548335664OASAS (Article 32) Provider 1638375 25360 1093731069OMH (Article 31) Provider n 28280 1255629127OASAS (Article 32) Provider 1420800 14770 1538180351OASAS (Article 32) Provider n 19400 1013976976OPWDD (Article 16) provider 3214835 22940 1669528709OPWDD (Article 16) provider 1994476 18730 1609915206OPWDD (Article 16) provider 356854 20920 1790964591OPWDD (Article 16) provider n/a 28240 1790852259OPWDD (Article 16) provider n/a 23510 1679631261Diagnostic & Treatment Center (Non FQHC) 245689 7002293R 1063637817OPWDD (Article 16) provider n/a 22280 1770885550OPWDD (Article 16) provider 2923908 25940 1841335197OPWDD (Article 16) provider n/a 93070 1336497627OPWDD (Article 16) provider n/a 13340 1326282229OPWDD (Article 16) provider 356905 20590 1215004353OPWDD (Article 16) provider 1373404 23820 1801014634OPWDD (Article 16) provider 2377186 22270 1992881148OPWDD (Article 16) provider 813103 71230 1033270665OPWDD (Article 16) provider 1584078 28270 1972727972OASAS (Article 32) Provider 3008151 160410665 1437106994OPWDD (Article 16) provider 243949 28250 1184661290OMH (Article 31) Provider 1312918 50490 1477684967OPWDD (Article 16) provider 2495141 1458 1710957683OPWDD (Article 16) provider 426884 20940 1215195904OPWDD (Article 16) provider 876971 21360 1013138189OMH (Article 31) Provider n/a 8048001A 1588926703OPWDD (Article 16) provider 2800457 22250 1649442229

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

1 2 3 4 5 6 7 8 9 10

Organization Name Address City State Zip Person Phone # Extension Email

1 ACMH, Inc. (FKA The Association for Rehabilitative Case Management and HoNO 254 W. 31st Street, 9th Floor New York NY 10001 Daniel K. Johansson, Exec. V.P./C2122748558 214 djohansson@acmhnyc.org2 Advance Care Alliance NO 60 East 42nd Street, Suite 1762 New York NY 10165 Ira Machowsky 212-366-8444 imachowsky@fegs.org3 Affinity Health Plan NO 2500 Halsey Street Bronx NY 10461 Glenn A. MacFarlane, CPA 718-794-2328 GMacFarlane@AffinityPlan.org4 AgeWell New York, LLC NO 1991 Marcus Avenue, Suite M201 Lake Success NY 11042 Tara Buonocore-Rut 718-289-2669 tbuonocore@agewellnewyork.com5 AIDS SERVICE CENTER NYC dba Allied Service Center NYC (ASCNYC) NO 41 East 11th Street, 5th Floor New York NY 10003 Marcy Rae Thompson 212-645-0875 307 marcy@ascnyc.org6 Coordinated Behavioral Care, Inc. (CBC) No 315 Hudson Street New York NY 10013 Donna Colonna 917-408-1600 dcolonna@sus.org7 Pibly Residential Treatment Programs No 2415 Westchester Avenue Bronx NY 10461 Madeline Weiss, LMSW 718-863-4100 madelin@pibly.org8 Amerigroup No 360 West 31st Street, 3rd Floor New York NY 10001 Justin Frazer 212-578-5212 justin.frazer@amerigroup.com9 Amida Care No 235 West 35th, 7th Floor New York NY 10001 Doug Wirth 646-786-7805 dwirth@amidacareny.org

10 Boom! Health NO 540 East Fordham Road Bronx NY 10451 Nunzio Signorella 718-292-7718 427 nsignorella@boomhealth.org 11 Bronx Health Home NO 1276 Fulton Ave, Suite 200 Bronx NY 10456 Sam Shutman 718-901-8920 sshutman@bronxleb.org12 Bronx Parents Housing Network, Inc. NO 1171 Washington Avenue Bronx NY 10456 Jose LaBoy 646-387-7194 jlaboy@bphn.org13 Bronx Regional Health Information Organization NO 2275 Olinville Avenue Bronx NY 10467 Charles Scaglione 718-708-6633 cscaglio@bronxrhio.org14 Community Care Management Partners LLC (CCMP) NO 1250 Broadway, 22nd Floor New York NY 10001 Alyssa Lord 212-216-9911 alyssa.lord@vnsny.org15 Dennelisse Corporation NO 349 East 149th Street, Suite 605 Bronx NY 10451 Sandra Diaz 718-993-5580 sdiaz@homecareny.org 16 Dr. Emily Women's Health Center NO 560 Southern Boulevard Bronx NY 10455 William Knorr 718-585-1010 ella@DrEmily.com17 EAC/TASC Mental Health Court Program NO 938 Sheridan Ave Bronx NY 10451 Dr. Merrill Rotter 914-558-1691 merrill.rotter@gmail.com 18 East Tremont Medical Center NO 930 East Tremont Bronx NY 10460 Dr. H. Ahmed 718-764-1661 easttremontmedicalcenter@hotmail.c19 Essen Medical Associates, PC NO 2015 Grand Concourse Bronx NY 10452 Sumir Sahgal, MD 718-299-7295 ssahgal@essenmed.com 20 Gay Men's Health Crisis NO 446 West 33rd Street New York NY 10011 Kelsey Louie 212-367-1000 kelsey.louie@gmhc.org21 Geel Community Services, Inc. NO 2516 Grand Ave Bronx NY 10468 Maria Matias 718-367-1900 geelcsinc@aol.com 22 Goodwill Industries of Greater New York and Northern New Jersey, Inc. NO 4-21 27th Ave Astoria NY 11102 Jenna Tine, LCSW 718-777-6312 jtine@goodwillny.org23 NAMI-NYC Metro NO 505 8th Avenue New York NY 10018 Wendy Brennan 2126843365 wbrennan@naminyc.org24 National Association on Drug Abuse Problems, Inc. (NADAP, Inc.) YES 355 Lexington Avenue, 2nd Floor New York NY 10017 John A. Darin, President and CE 2129861170 132 jdarin@nadap.org25 NYC Department of Corrections, Rikers Island No 15-00 Hazen Street East Elmhurst NY 11370 Alison Jordan 9177486145 ajordan@health.nyc.gov26 Primary Care Development Corporation No 22 Cortlandt Street, 12th Floor New York NY 10007 Ronda Kotelchuck 212-437-3917 rkotelchuck@pcdc.org27 Richmond Home Need Services. Inc. NO 505 8th Avenue Suite 303 New York NY 10018 Christine Sileo (212) 947-1600 csileo@homecareny.com28 Salvation Army Yes 601 Crescent Avenue Bronx NY 10458 Nicole Biancamano 718-329-5410 201 nicole.biancamano@use.salvationarm29 Hospice of New York, LLC No 45-18 Court Street, Suite 500 Long Island City NY 11101 John Diaz-Chermack 347-226-4804 john.diazchermack@hospiceny.com30 Hostos Community College – Division of Continuing Education & WorkforcNO 560 Exterior St Bronx NY 10451 Fern Chan 718-518-6830 FCHAN@hostos.cuny.edu 31 iHealth NO James Schiller, PHD 718-401-5733 ihealthcoordinator@gmail.com 32 Institute for Puerto Rican/Hispanic Elderly NO 1619 East 174th Street Bronx NY 10472 Sulieka Cabrera 917-208-3651 sulieka@iprhe.org33 Lehman College NO 250 Bedford Park Blvd W Bronx NY 10468 Ricardo Fernandez 718-960-8111 ricardo.fernandez@lehman.cuny.edu 34 1199 SEIU No 310 West 43rd Street New York NY 10036 Aida Morales 212-603-1152 aidam@1199.org35 HELP/PSI Inc. Yes 1765 Townsend Avenue Bronx NY 10453 Sara Gillen 718.681.8700 3264 sgillen@projectsamaritan.org36 Resource Medical Services, PC d.b.a. ArcWell Medical No 250 West 49th Street, Suite 405 New York NY 10019 Stuart Weger 917-504-5718 sweger@arcwell.net37 Bluehaven Confidential Counseling and Psychotheraphy Services NO 20417 Hillside Ave, Suite 309 Hollis NY 11423 Tishaun Cook 347-506-3986 tcook@bluehavenconsueling.com38 God's Love We Deliver, Inc. NO 630 Flushing Avenue, 7th Floor Brooklyn NY 11206 Alissa Wassung 212-294-8171 awassung@glwd.org

2.2) Partner Organizations - Contact Information"OTHER" Provider Types

SN Qualified (Y/N)

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39 Coordinated Behavioral Care, Inc. NO 304 Park Ave South, 11th FL New York NY 10010 Danika Mills 212- 590-2407 dmills@cbcare.org40 LIBERTY BEHAVIORAL MANAGEMENT, CORP. NO 395 Grand St, Jersey City, NJ Jersey City NJ 7446 Roy Wallach 800-989-6446 92 rwallach@libertymgt.com41 KIRBY MANHATTAN PSYCHIATRIC CENTER NO 600 E 125th St New York NY 10035 Franklin Edwards (646) 672-6767 franklin.edwards@omh.ny.gov42 PATHWAYS TO HOUSING, INC. NO 186 East 123rd. St., 4th fl. New York NY 10035 Elena Peabody 212-289-0000 1115 epeabody@pathwaystohousing.org43 PRAXIS HOUSING INITIATIVES, INC. NO 17 Battery Place New York NY 10004 Svein Jorgensen, CEO (212) 293-8404 sjorgensen@praxishousing.org 44 SELFHELP COMMUNITY SERVICES Home Attendent Corporation NO 521 Eighth Avenue New York NY 10018 Stuart Kaplan 212.971.772445 STRIVE NEW YORK, INC. NO 240 East 123rd Street New York NY 10035 Lawrence Jackson 212-360-1100 Larry@striveinternationl.com46 TRANSCARE NEW YORK, INC. NO 1 Metrotech Ctr, 20th Floor Brooklyn NY 11201 Doug Key 718-763-8888 dougk@transcare.com47 The Urban Institute for Behavioral Health NO 40 Rector Street, New York, NY New York NY 10006 Andrew Cleek 212-385-3030 x 3179 andrew.cleek@nyu.edu48 Balance Accountable Care Network NO 5030 Broadway, Ste. 808 New York NY 10034 Dr. Oscar Fukilman (212) 567-1104 ofukilman@balanceaco.com 49 Harlem Medical Group PC NO 392 Bedford Park Blvd Bronx NY 10458 Biren Patel 516-971-0028 drbirenpatel@gmail.com50 Hemant Patel MD PC NO 33 W 125th Street New York NY 10027 Biren Patel 516-971-0028 drbirenpatel@gmail.com51 Hemant Patel Physicians PLLC NO 129 W 110th Street New York NY 10026 Biren Patel 516-971-0028 drbirenpatel@gmail.com52 Tracy Towers Medical PC NO 1560 Grand Concourse, #102 Bronx NY 10457 Biren Patel 516-971-0028 drbirenpatel@gmail.com53 UNITED HEALTHCARE/ COMMUNITY PLAN NO 77 Water Street, 14 th Floor, New York NY 10005 Matthew Bastien 2128988429 matthew_a_bastien@uhc.com54 Healthfirst NO 100 Church Street New York NY 10007 Susan Kwon 212.801.1505 skwon@healthfirst.org5556575859606162636465666768697071727374757677787980818283848586878889909192

skaplan@selfhelp.net

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93949596979899

100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146

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147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200

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201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254

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255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398399400401402403404405406407408409410411412413414415416

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

417418419420421422423424425426427428429430431432433434435436437438439440441442443444445446447448449450451452453454455456457458459460461462463464465466467468469470

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

471472473474475476477478479480481482483484485486487488489490491492493494495496497498499500501502503504505506507508509510511512513514515516517518519520521522523524

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562563564565566567568569570571572573574575576577578

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618619620621622623624625626627628629630631632

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

633634635636637638639640641642643644645646647648649650651652653654655656657658659660661662663664665666667668669670671672673674675676677678679680681682683684685686

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

687688689690691692693694695696697698699700701702703704705706707708709710711712713714715716717718719720721722723724725726727728729730731732733734735736737738739740

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

741742743744745746747748749750751752753754755756757758759760761762763764765766767768769770771772773774775776777778779780781782783784785786787788789790791792793794

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

795796797798799800801802803804805806807808809810811812813814815816817818819820821822823824825826827828829830831832833834835836837838839840841842843844845846847848

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

849850851852853854855856857858859860861862863864865866867868869870871872873874875876877878879880881882883884885886887888889890891892893894895896897898899900901902

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

903904905906907908909910911912913914915916917918919920921922923924925926927928929930931932933934935936937938939940941942943944945946947948949950951952953954955956

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

957958959960961962963964965966967968969970971972973974975976977978979980981982983984985986987988989990991992993994995996997998999

10001001100210031004100510061007100810091010

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

101110121013101410151016101710181019102010211022102310241025102610271028102910301031103210331034103510361037103810391040104110421043104410451046104710481049105010511052105310541055105610571058105910601061106210631064

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

106510661067106810691070107110721073107410751076107710781079108010811082108310841085108610871088108910901091109210931094109510961097109810991100110111021103110411051106110711081109111011111112111311141115111611171118

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

111911201121112211231124112511261127112811291130113111321133113411351136113711381139114011411142114311441145114611471148114911501151115211531154115511561157115811591160116111621163116411651166116711681169117011711172

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DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

117311741175117611771178117911801181118211831184118511861187118811891190119111921193119411951196119711981199120012011202120312041205120612071208120912101211121212131214121512161217121812191220122112221223122412251226

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

122712281229123012311232123312341235123612371238123912401241124212431244124512461247124812491250125112521253125412551256125712581259126012611262126312641265126612671268126912701271127212731274127512761277127812791280

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

128112821283128412851286128712881289129012911292129312941295129612971298129913001301130213031304130513061307130813091310131113121313131413151316131713181319132013211322132313241325132613271328132913301331133213331334

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

133513361337133813391340134113421343134413451346134713481349135013511352135313541355135613571358135913601361136213631364136513661367136813691370137113721373137413751376137713781379138013811382138313841385138613871388

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

138913901391139213931394139513961397139813991400140114021403140414051406140714081409141014111412141314141415141614171418141914201421142214231424142514261427142814291430143114321433143414351436143714381439144014411442

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

144314441445144614471448144914501451145214531454145514561457145814591460146114621463146414651466146714681469147014711472147314741475147614771478147914801481148214831484148514861487148814891490149114921493149414951496

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

149714981499150015011502150315041505150615071508150915101511151215131514151515161517151815191520152115221523152415251526152715281529153015311532153315341535153615371538153915401541154215431544154515461547154815491550

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

155115521553155415551556155715581559156015611562156315641565156615671568156915701571157215731574157515761577157815791580158115821583158415851586158715881589159015911592159315941595159615971598159916001601160216031604

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

160516061607160816091610161116121613161416151616161716181619162016211622162316241625162616271628162916301631163216331634163516361637163816391640164116421643164416451646164716481649165016511652165316541655165616571658

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

165916601661166216631664166516661667166816691670167116721673167416751676167716781679168016811682168316841685168616871688168916901691169216931694169516961697169816991700170117021703170417051706170717081709171017111712

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

171317141715171617171718171917201721172217231724172517261727172817291730173117321733173417351736173717381739174017411742174317441745174617471748174917501751175217531754175517561757175817591760176117621763176417651766

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

176717681769177017711772177317741775177617771778177917801781178217831784178517861787178817891790179117921793179417951796179717981799180018011802180318041805180618071808180918101811181218131814181518161817181818191820

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

182118221823182418251826182718281829183018311832183318341835183618371838183918401841184218431844184518461847184818491850185118521853185418551856185718581859186018611862186318641865186618671868186918701871187218731874

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

187518761877187818791880188118821883188418851886188718881889189018911892189318941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

198319841985198619871988198919901991199219931994199519961997199819992000

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

11 12 15 16

"OTHER"- Provider Type MMIS NPI #1 NPI #2

OMH Supported Housing 1303786 1588815302IDD Provider Organization n/a n/a n/aManaged Care Organization 2802899 1679859904 n/aManaged Care Organization 3481927 1740520949 n/aCare Management 1484019 1710109947 n/aCare Management n/a 1730451071 n/aSupported Housing 1304067 1831399146 n/aManaged Care Organization 1617894 1649254806 n/aManaged Care Organization 2191582 1770868226 n/aCare Management 1243521 1669642211 n/aHealth Home 476022 1417027558 n/aCare Management n/a 1396180287 n/aHealth Information Organization n/a n/a n/aHealth Home 3606902 1366780850 n/aCare Management 144999 1043385214 n/aWomen's Health Center n/a 1376670547 n/aCourt for Persons with Mental Illnesses 2249145 1538594049 n/aPrimary Care Facility 1672999 1336173194 n/aPrimary Care Facility 2880591 1366418709 n/aCare Management n/a 1992903389 n/aSupported Housing 1304934 1477700839 n/aPersonalized Recovery Oriented Services 2997340 1801080478 n/aFamily and person with mental illness led suppor n/a n/a n/aCare Management 3439925 1295006526 n/aCorrectional Facility n/a n/a n/aPrimary Care Consulting Company n/a n/a n/aCare Management 1276080 1982835807 n/aPreferred Provider Organization 1391120 1902080401 n/aHospice 1792052 1013001197 n/aCommunity College n/a n/a n/aAdvocacy Organization n/a n/a n/aCare Management 1975626 1093800211 n/aCommunity College n/a n/a n/aUnion n/a n/a n/aHealth Home Care Management (formerly COBRA2995339 1346464989 n/aPrimary Care Provider 3443996 1194093468 n/aCounseling Center 3712356 1881039022 n/aMedically Tailored Home-Delivered Meals n/a 1467646281 n/a

1649420092

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

Health Home 3559515 1730451071 n/aOut-of-State Behavioral Health Providers 7491808 1811076607 n/aPsychiatric Hospital n/a 1932283876 n/aSupported Housing 2374885 1861419707 n/aSupported Housing n/a n/a n/aLicensed Home Health 922216 1831264001 n/aSocial Services Agency n/a n/a n/aAmbulance Company 2994723 1215930193 n/aCommunity Based Behavioral Health Consortium n/a n/a n/aAccountable Care Organization n/a n/a n/aPrimary Care Facility 3464362 1851650550 n/aPrimary Care Facility 3399337 1750304978 n/aPrimary Care Facility 1740909 1518197052 n/aPrimary Care Facility n/a n/a n/aManaged Care Organization 1403176 1528296746 n/aManaged Care Organization 1479670 1922384676 n/a

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Updated Section 2 Form Partner Organization Contact Info

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

1 Bronx United IPA New York 140 WADSWORTH AVE APT 4 New York NY 10033 DR. BIENVENIDO FAJARDO 646-417-05002 Bienvenido Fajardo Physician Bronx United IPA YES 1528153467 1016260 163674 New York New York NY 10040 BIENVENIDO FAJARDO M.D. (646) 417-05003 Muhammad Adam Physician Bronx United IPA YES 1346329984 1591602 200111 Bronx 1983 University Ave. Bronx NY 10453 MUHAMMAD SANNI ADAM M(718) 866-05104 Miguel Avila-Rondon Physician Bronx United IPA NO 1518936335 n/a 193694 New York 982 Columbus Ave. New York NY 10025 DR. MIGUEL AVILA-RONDON (212) 862-90465 Barry Baker Physician Bronx United IPA NO 1619078086 700156 147006 Bronx 3665 E Tremont Ave Bronx NY 10465 BARRY A BAKER MD (718) 863-77556 Jagdish Bansal Physician Bronx United IPA NO 1518926724 199106 111144 Bronx 1807 Randall Ave. Bronx NY 10473 JAGDISH BANSAL M.D. (718) 842-38127 Om P Bansal Physician Bronx United IPA NO 1841379138 806079 156961 Kings 3 Sutter Ave. Brooklyn NY 11212 DR. OM PRAKASH BANSAL M (718) 604-72428 Francisco Bautista-Mena Physician Bronx United IPA NO 1356468698 1136727 171183 Bronx 3485 E Tremont Avenue Bronx NY 10465 FRANCISCO D BAUTISTA M.D.(718) 383-08309 Aramis Bermudez Physician Bronx United IPA NO 1992738769 1973977 207135 Bronx 2016 Bronxdale Ave Bronx NY 10462 ARAMIS ANTONIO BERMUDEZ (718) 918-1372

10 Evelyn Cordero Physician Bronx United IPA NO 1003823584 790547 146024 Bronx 941 Castle Hill Ave. Bronx NY 10473 DR. EVELYN CORDERO MD (718) 792-311711 Carmen Costas-Katz Physician Bronx United IPA NO 1407918675 1843672 203363 Bronx 625 East Fordham Bronx NY 10458 CARMEN SILVIA COSTAS-KAT (718)634-938412 Enrico D'Angelo Physician Bronx United IPA NO 1316030364 n/a 158217 Bronx 1803 Mahan Ave. Bronx NY 10461 DR. ENRICO D'ANGELO M.D. (718) 409-276213 Samuel De Leon Physician Bronx United IPA NO 1770589111 n/a 186141 Bronx 1070 Southern Blvd. Bronx NY 10459 DR. SAMUEL A. DELEON M.D.(718) 589-244014 Alan Diaz Physician Bronx United IPA YES 1104936335 1725548 188017 Bronx 2494 Williamsbridge Road Bronx NY 10469 DR. ALAN DIAZ M.D. (718) 652-180215 Luis Diaz Physician Bronx United IPA NO 1619975091 957460 161575 Bronx 1217 Castle Hill Ave. Bronx NY 10462 DR. LUIS A DIAZ MD (718) 518-920016 Louis Difazio Physician Bronx United IPA NO 1245231083 872546 151941-1 Bronx 2371 Arthur Ave., Bronx NY 10458 LOUIS JOHN DIFAZIO M.D. (718) 364-619917 Carlos Driggs Physician Bronx United IPA YES 1851379911 1408891 179708 Bronx 1957 Williamsbridge Road Bronx NY 10461 DR. CARLOS FELIX DRIGGS MD(718) 828-606018 Gregory Emili Physician Bronx United IPA YES 1932287042 2096748 211144 Bronx 4626 White Plains Rd Bronx NY 10470 DR. GREGORY EMILI M.D (718) 944-177619 Carl Franzetti Physician Bronx United IPA NO 1124111521 1018639 167912 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. CARL J FRANZETTI D.O (718) 543-270020 Leticia Gonzalez Physician Bronx United IPA NO 1174616577 1886704 185409 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. LETICIA R GONZALEZ M.D.(718) 543-270021 Jill Groves Physician Bronx United IPA NO 1700979119 2611085 227600 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. JILL GROVES M.D. (718) 543-270022 Rafael Guillen Physician Bronx United IPA NO 1861430076 n/a 233234 Queens 82-11 37th Avenue 4th Floor Jackson Heights NY 11372 RAFAEL A. GUILLEN M.D. (718) 401-230023 Renee Hernandez Physician Bronx United IPA NO 1427152750 2199526 218949 Bronx 916 Rev James A Polite Ave., Ste. Bronx NY 10459 RENEE HERNANDEZ MD (718) 620-224424 Teresa Hervada Physician Bronx United IPA NO 1194823237 n/a 211433 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 TERESA HERVADA M.D. (718) 543-270025 Richard Izquierdo Physician Bronx United IPA NO 1689766776 n/a 86624 Bronx 1070 Southern Blvd. Bronx NY 10459 RICHARD IZQUIERDO M.D. (718) 589-454126 Lamercie Jean-Jacques Physician Bronx United IPA NO 1427395672 n/a 267751 Bronx 625 East Fordham RD Bronx NY 10458 DR. LAMERCIE MONARE JEAN-(718) 933-190027 William E Kalafatic Physician Bronx United IPA YES 1992960538 n/a 241203 Bronx 1049 E. 163rd Street Bronx NY 10458 WILLIAM EDWARD KALAFATIC(516) 902-940028 William H Kalafatic Physician Bronx United IPA NO 1578630034 236026 126527 Bronx 1049 E. 163rd Street Bronx NY 10458 WILLIAM H KALAFATIC MD (212) 546-068329 Ajith Karayil Physician Bronx United IPA YES 1104011618 n/a 251400 Bronx 1561 Westchester Avenue Bronx NY 10472 AJITH K KARAYIL MD (718) 842-890030 Vijay Khatiwala Physician Bronx United IPA YES 1831160589 1424051 193352 Bronx 640 E. 233rd St. Bronx NY 10466 DR. VIJAY KHATIWALA M.D. (718) 325-350031 Amy Laude Physician Bronx United IPA NO 1609032291 n/a 270733 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. AMY KRISTIN LAUDE MD (718) 543-270032 Frank Maselli Physician Bronx United IPA NO 1215020607 995377 156173 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. FRANK MASELLI M.D. (718) 543-270033 Chandra Menon Physician Bronx United IPA NO 1295810406 n/a 119981 Bronx 1622 Crosby Ave. Bronx NY 10461 CHANDRA MENON MD (718) 828-445034 Sajjad Mohammad Physician Bronx United IPA YES 1033290242 695941 201036 Bronx 625 East Fordham Rd Bronx NY 10458 DR. SAJJAD MOHAMMAD M. (646) 523-047235 Hector Rodriguez Navarro Physician Bronx United IPA NO 1811034077 n/a 152348-1 Bronx 1025 Grand Concourse Bronx NY 10452 DR. HECTOR RAFAEL RODRIG (718) 681-424236 S. Steve Okhravi Physician Bronx United IPA NO 1316940489 n/a 221390 Bronx 1715 University Ave. Bronx NY 10453 SIAVASH OKHRAVI MD (212) 962-660037 Anil Patel Physician Bronx United IPA NO 1497739635 798274 151060 Nassau 607 Fulton Ave Hempstead NY 11550 MR. ANIL S PATEL (516) 489-670038 Madan Paul Physician Bronx United IPA YES 1740358332 232980 123917 Bronx 825 Walton Ave Bronx NY 10451 MADAN BHATIA PAUL MD (718) 402-180039 Salvador Perez Physician Bronx United IPA YES 1104024314 2872273 241980 Corona 100-05 Roosevelt Ave., Ste. 201 Corona NY 11368 DR. SALVADOR O PEREZ MD (347) 201-456740 Edgar Pimentel Physician Bronx United IPA NO 1598856007 1688513 203059 Bronx 2016 Bronxdale Ave. Bronx NY 10462 EDGAR ANDREW PIMENTEL D.(212) 567-377741 Frank Pintauro Physician Bronx United IPA NO 1811989205 733248 141999 Bronx 1750 Seminole Ave. Bronx NY 10461 FRANK L PINTAURO MD (718) 863-307942 Robert Pintauro Physician Bronx United IPA NO 1942393343 1890904 160692 Bronx 2460 Mickle Ave. Bronx NY 10461 DR. ROBERT D PINTAURO M.D(718) 824-552543 Robin Pinzon Physician Bronx United IPA NO 1912296641 n/a 258746 Bronx 3050 Corlear Ave. , Ste. 201 Bronx NY 10463 DR. ROBIN PINZON M.D. (718) 543-270044 Michael Rabinowitz Physician Bronx United IPA YES 1619979978 n/a 169111 Bronx 787 Lydig Ave. Bronx NY 10462 (718) 863 - 777445 Realba Rodriguez-Iglesias Physician Bronx United IPA YES 1780978213 3427754 263494 Bronx 2494 Williamsbridge Road Bronx NY 10462 DR. REALBA RODRIGUEZ IGLE(718) 652-180246 Ludmila Sedlackova Physician Bronx United IPA NO 1609969013 1886731 205197 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. LUDMILA SEDLACKOVA M(718) 543-270047 Robert Shargani Physician Bronx United IPA NO 1588736953 n/a 221729 Bronx 2160 Bronx Park E. , Ste. 1D Bronx NY 10462 ROBERT SHARGANI (516) 627-655948 Maurice Szteinbok Physician Bronx United IPA NO 1124155627 171522 100075 New York 408 West 57 St., Ste. 1B New York NY 10019 DR. MAURICE SZTEINBOK M.D(718) 316-380349 Fassil Teffera Physician Bronx United IPA YES 1801884408 1527384 196877 Bronx 2426 Eastchester Rd., Ste. 1 Bronx NY 10469 MR. FASSIL TEFFERA MD (718) 708-472650 Jeanette Torres Physician Bronx United IPA YES 1447355102 n/a 199015 Bronx 1070 Southern Blvd. Bronx NY 10459 JEANETTE TORRES M.D. (718) 589-454151 Roger Villi Physician Bronx United IPA NO 1376636787 1438706 187473 Bronx 3050 Corlear Ave., Ste. 201 Bronx NY 10463 DR. ROGER A VILLI M.D (718) 543-270052 Excelsior Medical IPA, LLC Queens 9320a Roosevelt Ave Jackson Heights NY 11372 Emilio Villegas, MD 718-334-6700

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

2 SICKLES ST

Dr. Michael Ray Rabinowitz MD

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

53 Balance Medical IPA, Inc New York 5030 Broadway New York NY 10034 Oscar Fukilman, MD54 Corinthian Medical IPA, Inc 5030 Broadway New York NY 10034 Ramon Tallaj, MD 212-740-8294 555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

100101102103104

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398399400401402403404405406407408409410411412413414415416

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

417418419420421422423424425426427428429430431432433434435436437438439440441442443444445446447448449450451452453454455456457458459460461462463464465466467468

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

469470471472473474475476477478479480481482483484485486487488489490491492493494495496497498499500501502503504505506507508509510511512513514515516517518519520

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

521522523524525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562563564565566567568569570571572

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618619620621622623624

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

625626627628629630631632633634635636637638639640641642643644645646647648649650651652653654655656657658659660661662663664665666667668669670671672673674675676

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

677678679680681682683684685686687688689690691692693694695696697698699700701702703704705706707708709710711712713714715716717718719720721722723724725726727728

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

729730731732733734735736737738739740741742743744745746747748749750751752753754755756757758759760761762763764765766767768769770771772773774775776777778779780

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

781782783784785786787788789790791792793794795796797798799800801802803804805806807808809810811812813814815816817818819820821822823824825826827828829830831832

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

833834835836837838839840841842843844845846847848849850851852853854855856857858859860861862863864865866867868869870871872873874875876877878879880881882883884

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

885886887888889890891892893894895896897898899900901902903904905906907908909910911912913914915916917918919920921922923924925926927928929930931932933934935936

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

937938939940941942943944945946947948949950951952953954955956957958959960961962963964965966967968969970971972973974975976977978979980981982983984985986987988

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

989990991992993994995996997998999

10001001100210031004100510061007100810091010101110121013101410151016101710181019102010211022102310241025102610271028102910301031103210331034103510361037103810391040

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1041104210431044104510461047104810491050105110521053105410551056105710581059106010611062106310641065106610671068106910701071107210731074107510761077107810791080108110821083108410851086108710881089109010911092

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1093109410951096109710981099110011011102110311041105110611071108110911101111111211131114111511161117111811191120112111221123112411251126112711281129113011311132113311341135113611371138113911401141114211431144

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1145114611471148114911501151115211531154115511561157115811591160116111621163116411651166116711681169117011711172117311741175117611771178117911801181118211831184118511861187118811891190119111921193119411951196

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1197119811991200120112021203120412051206120712081209121012111212121312141215121612171218121912201221122212231224122512261227122812291230123112321233123412351236123712381239124012411242124312441245124612471248

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1249125012511252125312541255125612571258125912601261126212631264126512661267126812691270127112721273127412751276127712781279128012811282128312841285128612871288128912901291129212931294129512961297129812991300

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1301130213031304130513061307130813091310131113121313131413151316131713181319132013211322132313241325132613271328132913301331133213331334133513361337133813391340134113421343134413451346134713481349135013511352

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1353135413551356135713581359136013611362136313641365136613671368136913701371137213731374137513761377137813791380138113821383138413851386138713881389139013911392139313941395139613971398139914001401140214031404

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1405140614071408140914101411141214131414141514161417141814191420142114221423142414251426142714281429143014311432143314341435143614371438143914401441144214431444144514461447144814491450145114521453145414551456

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1457145814591460146114621463146414651466146714681469147014711472147314741475147614771478147914801481148214831484148514861487148814891490149114921493149414951496149714981499150015011502150315041505150615071508

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1509151015111512151315141515151615171518151915201521152215231524152515261527152815291530153115321533153415351536153715381539154015411542154315441545154615471548154915501551155215531554155515561557155815591560

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1561156215631564156515661567156815691570157115721573157415751576157715781579158015811582158315841585158615871588158915901591159215931594159515961597159815991600160116021603160416051606160716081609161016111612

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1613161416151616161716181619162016211622162316241625162616271628162916301631163216331634163516361637163816391640164116421643164416451646164716481649165016511652165316541655165616571658165916601661166216631664

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1665166616671668166916701671167216731674167516761677167816791680168116821683168416851686168716881689169016911692169316941695169616971698169917001701170217031704170517061707170817091710171117121713171417151716

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1717171817191720172117221723172417251726172717281729173017311732173317341735173617371738173917401741174217431744174517461747174817491750175117521753175417551756175717581759176017611762176317641765176617671768

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1769177017711772177317741775177617771778177917801781178217831784178517861787178817891790179117921793179417951796179717981799180018011802180318041805180618071808180918101811181218131814181518161817181818191820

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1821182218231824182518261827182818291830183118321833183418351836183718381839184018411842184318441845184618471848184918501851185218531854185518561857185818591860186118621863186418651866186718681869187018711872

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1873187418751876187718781879188018811882188318841885188618871888188918901891189218931894189518961897189818991900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

1925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

2.3) IPA/Physicians - Contact Information

Certified_Nurse_Midwife

Dentist State of New York Department of HealthNurse_Practitioner Delivery System Reform Incentive Payment (DSRIP) ProgramPhysician IPA/Physician ListPhysicians Assistant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physician Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension

Physicians Type: ONLY choose from the following:

Physician Type (See Instructions) Individual OR Group Name

SN Qualified (Y/N)

197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

16

Email

bfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.combfajardomd@gmail.comvillega@gmail.com

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

16

Email

ojf820@yahoo.comramontallaj@cm-ipa.com

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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Email

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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DSRIP Project Design Grant Application Section 2.3 IPA/Physician List

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05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension Email

1 Evers Pharmacy No 1801162375 32157196 31260 Bronx 226 East 144th Street Bronx NY 10451 Anthony Varikos 718-292-0900 anthony@eversrx.com2 No 1821079617 1932829 24537 Bronx 255 E. Gun Hill Road Bronx NY 10467 Ajay D. Desi 201.478.0930 admin@ovalpharmacy.com3 Choice One Pharmacy No 1184048720 n/a 32518 Bronx 1550 University Avenue Bronx NY 10452 Rafael Perez 718-450-8922 n/a4 Cityview Pharmacy No 1679544563 2721382 27546 Queens 23-07 Astoria Boulevard Astoria NY 11102 HARRY XIDIAS info@cityviewpharmacy.com5 Echo Salveo Specialty Pharmacy No 1740498245 2921231 28357 Queens 39-50 Crescent Street Long Island City NY 11101 MICHAEL GLEIT (718) 391 - 0303 info@echosalveo.com6789

1011121314151617181920212223242526272829303132333435363738394041424344454647

SN Qualified (Y/N)

OVAL PHARMACY

718.545.2550

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

4849505152535455565758596061626364656667686970717273747576777879808182838485868788899091929394

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

9596979899

100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

377378379380381382383384385386387388389390391392393394395396397398399400401402403404405406407408409410411412413414415416417418419420421422423

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

424425426427428429430431432433434435436437438439440441442443444445446447448449450451452453454455456457458459460461462463464465466467468469470

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

471472473474475476477478479480481482483484485486487488489490491492493494495496497498499500501502503504505506507508509510511512513514515516517

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

518519520521522523524525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562563564

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

565566567568569570571572573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

612613614615616617618619620621622623624625626627628629630631632633634635636637638639640641642643644645646647648649650651652653654655656657658

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

659660661662663664665666667668669670671672673674675676677678679680681682683684685686687688689690691692693694695696697698699700701702703704705

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

706707708709710711712713714715716717718719720721722723724725726727728729730731732733734735736737738739740741742743744745746747748749750751752

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

753754755756757758759760761762763764765766767768769770771772773774775776777778779780781782783784785786787788789790791792793794795796797798799

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

800801802803804805806807808809810811812813814815816817818819820821822823824825826827828829830831832833834835836837838839840841842843844845846

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

847848849850851852853854855856857858859860861862863864865866867868869870871872873874875876877878879880881882883884885886887888889890891892893

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

894895896897898899900901902903904905906907908909910911912913914915916917918919920921922923924925926927928929930931932933934935936937938939940

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

941942943944945946947948949950951952953954955956957958959960961962963964965966967968969970971972973974975976977978979980981982983984985986987

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

988989990991992993994995996997998999

10001001100210031004100510061007100810091010101110121013101410151016101710181019102010211022102310241025102610271028102910301031103210331034

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

10351036103710381039104010411042104310441045104610471048104910501051105210531054105510561057105810591060106110621063106410651066106710681069107010711072107310741075107610771078107910801081

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

10821083108410851086108710881089109010911092109310941095109610971098109911001101110211031104110511061107110811091110111111121113111411151116111711181119112011211122112311241125112611271128

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

11291130113111321133113411351136113711381139114011411142114311441145114611471148114911501151115211531154115511561157115811591160116111621163116411651166116711681169117011711172117311741175

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

11761177117811791180118111821183118411851186118711881189119011911192119311941195119611971198119912001201120212031204120512061207120812091210121112121213121412151216121712181219122012211222

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

12231224122512261227122812291230123112321233123412351236123712381239124012411242124312441245124612471248124912501251125212531254125512561257125812591260126112621263126412651266126712681269

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

12701271127212731274127512761277127812791280128112821283128412851286128712881289129012911292129312941295129612971298129913001301130213031304130513061307130813091310131113121313131413151316

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

13171318131913201321132213231324132513261327132813291330133113321333133413351336133713381339134013411342134313441345134613471348134913501351135213531354135513561357135813591360136113621363

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

13641365136613671368136913701371137213731374137513761377137813791380138113821383138413851386138713881389139013911392139313941395139613971398139914001401140214031404140514061407140814091410

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

14111412141314141415141614171418141914201421142214231424142514261427142814291430143114321433143414351436143714381439144014411442144314441445144614471448144914501451145214531454145514561457

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

14581459146014611462146314641465146614671468146914701471147214731474147514761477147814791480148114821483148414851486148714881489149014911492149314941495149614971498149915001501150215031504

05/09/2023 document.xlsx

DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

1 2 3 4 5 6 7 8 10 11 12 13 14 15

Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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Pharmacy Name NPI MMIS License # County Address City State Zip Contact Name Phone # Extension EmailSN Qualified (Y/N)

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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DSRIP Project Design Grant Application Section 2.4 Pharmacy List

2.4) Pharmacy - Contact Information

State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) Program

Pharmacy List

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

Section 10Project Advisory Committee - PAC

10.1) How will the Project Advisory Committee assist the emerging Performing Provider System in the development of its DSRIP Project Plan? (Restricted to 4500 characters)Characters used: 4407

Each emerging Performing Provider System (PPS) is required to form a Project Advisory Committee (PAC). The PAC will advise emerging Performing Provider Systems on all elements of their DSRIP Project Plans and should include representation from each of the emerging PPS partners as well as workers and/or relevant unions. Unless an alternative structure is being proposed. Project Advisory Committee representatives should be determined using the following process:

1. Organizational representatives:a. Emerging PPS partners with more than 50 employees are required to have an organizational (managerial) representative participate in the PAC.b. Emerging PPS partners with less than 50 employees have the option of selecting an organizational (managerial) representative to participate in the PAC.

2. Worker representatives:a. Partner organizations that are not unionized and have over 50 employees must develop a process to elect a worker (non-managerial employee) representative to participate in the PAC. b. For non-unionized partner organizations with less than 50 employees, the employees have the option of electing a worker (non-managerial employee) representative to participate in the PAC if they so choose.

3. Union Representatives:a. Partner organizations that are unionized and have over 50 employees must designate a union representative to participate in the PAC. If a particular union represents workers from multiple emerging PPS partners, one representative from that union is sufficient to satisfy PAC requirements. b. For unionized partner organizations with less than 50 employees, the union has the option of designating a union representative to participate in the PAC if they so choose.

The Performing Provider System (PPS) to date is comprised of a 24-member Project Advisory Committee (PAC); roughly 200 partnering, health care, and community-based organizations; and dozens of physician partners. Three formal meetings have taken place, the first with well over 100 attendees, in order to develop regional consensus for DSRIP projects and goals, to formulate the PAC, and to develop the DSRIP Project Design Grant.

The PAC is comprised of leaders and staff across the health care continuum from hospitals, Federally Qualified Health Centers, a Diagnostic and Treatment center, a certified home health agency, a mental health provider, a substance abuse provider, and a skilled nursing facility.PAC members have a history of working together to build consensus, as evidenced by the strategic development activities to form the Bronx Health Home and other collaborative initiatives.

To assist the PPS in the development of its DSRIP project plan, the PAC will set up a subcommittee structure with working groups that will be staffed by the PAC members, project collaborators, physician partners, and key stakeholders in the PPS. Six standing subcommittees will be formed initially: 1) Governance, with one organization and one vote from which a formal governance structure will emerge; 2) Strategic Interventions, to smooth the implementation of DSRIP projects ensuring that DSRIP goals are prioritized; 3) Community Needs Assessment (CNA), to provide oversight of the comprehensive CNA, facilitate broad stakeholder and community engagement, and results summaries; 4) Workforce Assessment, to review issues related to the PPS workforce needs and resources; 5) IT/Evaluation, to create a robust health information exchange and telecommunications vehicle in the PPS for planning and project implementation; 6) Collaborative Learning, to ensure continuous learning about DSRIP and to maintain the exchange of ideas. Working groups will be formed on each of the DSRIP projects to develop detailed implementation plans across the service area and organizations. Additional subcommittees may be identified in Year 0. Subcommittees will work with vendors, consultants, and other resources provided by the PAC.

In addition to these six core subcommittees, each DSRIP project will have a subcommittee assigned to ensure proper project implementation and feedback to the PAC on project milestones and barriers to deliverables. The expertise of subcommittee and PAC members, their organizations, project collaborators, and partners will comprise a pivotal component of the subcommittee capabilities as a whole. The PPS will rely on the critical expertise from Urban Health Plan to systematize effective continuous quality improvement (CQI) techniques and processes to track progress and improve outcomes. Additionally, the advanced IT capabilities of Bronx-Lebanon Hospital Center (BLHC) and the Bronx Regional Health Information Organization (RHIO) will help the PPS to build and efficiently manage a robust health information exchange, integrating information from multiple sources for PPS providers.

PAC members will use hands-on guidance with each subcommittee and, where necessary, will use the PAC’s authority to remove roadblocks that may occur or to change membership. The PAC will ensure that the subcommittees are prioritizing the program principles in planning and activities.

The subcommittees and the PAC will rely heavily on the DSRIP web site created for the emerging PPS. The web site will serve as an effective tool to warehouse, archive, communicate, disseminate, and receive key DSRIP information, as well as public comments from the service area. For the subcommittee and PAC members, the web site will include private communication tools as well as meeting notes, meeting schedules, and other features to enhance DSRIP planning activities.

The PAC will convene at least once a month during the DSRIP planning phase to share and discuss the subcommittee proposals, review and approve grant deliverables, and to guide the overall development of the planning and implementation phases. These meetings will provide the opportunity to assess and revise DSRIP project plans based on rapid cycle evaluations results, receive feedback on any aspects of the PPS initiatives, and discuss internal and external factors that will affect the PPS workforce, patients, and stakeholders.

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

The Performing Provider System (PPS) to date is comprised of a 24-member Project Advisory Committee (PAC); roughly 200 partnering, health care, and community-based organizations; and dozens of physician partners. Three formal meetings have taken place, the first with well over 100 attendees, in order to develop regional consensus for DSRIP projects and goals, to formulate the PAC, and to develop the DSRIP Project Design Grant.

The PAC is comprised of leaders and staff across the health care continuum from hospitals, Federally Qualified Health Centers, a Diagnostic and Treatment center, a certified home health agency, a mental health provider, a substance abuse provider, and a skilled nursing facility.PAC members have a history of working together to build consensus, as evidenced by the strategic development activities to form the Bronx Health Home and other collaborative initiatives.

To assist the PPS in the development of its DSRIP project plan, the PAC will set up a subcommittee structure with working groups that will be staffed by the PAC members, project collaborators, physician partners, and key stakeholders in the PPS. Six standing subcommittees will be formed initially: 1) Governance, with one organization and one vote from which a formal governance structure will emerge; 2) Strategic Interventions, to smooth the implementation of DSRIP projects ensuring that DSRIP goals are prioritized; 3) Community Needs Assessment (CNA), to provide oversight of the comprehensive CNA, facilitate broad stakeholder and community engagement, and results summaries; 4) Workforce Assessment, to review issues related to the PPS workforce needs and resources; 5) IT/Evaluation, to create a robust health information exchange and telecommunications vehicle in the PPS for planning and project implementation; 6) Collaborative Learning, to ensure continuous learning about DSRIP and to maintain the exchange of ideas. Working groups will be formed on each of the DSRIP projects to develop detailed implementation plans across the service area and organizations. Additional subcommittees may be identified in Year 0. Subcommittees will work with vendors, consultants, and other resources provided by the PAC.

In addition to these six core subcommittees, each DSRIP project will have a subcommittee assigned to ensure proper project implementation and feedback to the PAC on project milestones and barriers to deliverables. The expertise of subcommittee and PAC members, their organizations, project collaborators, and partners will comprise a pivotal component of the subcommittee capabilities as a whole. The PPS will rely on the critical expertise from Urban Health Plan to systematize effective continuous quality improvement (CQI) techniques and processes to track progress and improve outcomes. Additionally, the advanced IT capabilities of Bronx-Lebanon Hospital Center (BLHC) and the Bronx Regional Health Information Organization (RHIO) will help the PPS to build and efficiently manage a robust health information exchange, integrating information from multiple sources for PPS providers.

PAC members will use hands-on guidance with each subcommittee and, where necessary, will use the PAC’s authority to remove roadblocks that may occur or to change membership. The PAC will ensure that the subcommittees are prioritizing the program principles in planning and activities.

The subcommittees and the PAC will rely heavily on the DSRIP web site created for the emerging PPS. The web site will serve as an effective tool to warehouse, archive, communicate, disseminate, and receive key DSRIP information, as well as public comments from the service area. For the subcommittee and PAC members, the web site will include private communication tools as well as meeting notes, meeting schedules, and other features to enhance DSRIP planning activities.

The PAC will convene at least once a month during the DSRIP planning phase to share and discuss the subcommittee proposals, review and approve grant deliverables, and to guide the overall development of the planning and implementation phases. These meetings will provide the opportunity to assess and revise DSRIP project plans based on rapid cycle evaluations results, receive feedback on any aspects of the PPS initiatives, and discuss internal and external factors that will affect the PPS workforce, patients, and stakeholders.

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

Flexibility in the Project Advisory Committee (Q's 10.2 & 10.3)

10.2) Are you proposing an alternative structure for your Project Advisory Committee? Yes

If you answered "Yes" then:

- Answer question 10.3If you answered "No", then please skip 10.3

10.3) Please give an explanation of how your emerging PPS will be structuring your Project Advisory Committee? (Restricted to 5000 characters)~ See instructions for further clarification Characters used: 4913

^ The proposed alternative structure must still represent all key parties(Partner Organization/Union/Worker representatives) within the PPS.

For an emerging Performing Provider System with over 20 partnering organizations, qualifying PPS may propose an alternative PAC structure that will allow for a leaner committee as long as the proposed structure is still representative of all key parties within the PPS.

- Your emerging PPS must contain over 20 partnering organizations

Bronx-Lebanon Hospital Center (BLHC) has roughly 200 partnering organizations and is proposing an alternative structure for its Project Advisory Committee (PAC). Using the NYS Department of Health guidance, the resulting PAC size would be so large as to be unwieldy and inhibit the implementation of the DSRIP projects. Instead of an organizational representative from each of the participating partner organizations from each PPS partner with more than 50 employees, BLHC has included at least one organizational representative from the relevant provider types identified in the DSRIP application cover page, as well as other relevant community-based organizations. BLHC has conducted three PPS meetings to date, at which PAC members were recruited for PAC membership. The provider types on the 24-member PAC are identified below:• Voluntary Hospitals (1 member) – Bronx-Lebanon Hospital Center, in collaboration with the Dr. Martin Luther King, Jr. Health Center, the principal provider of medical, behavioral, and HIV services in the Central and South Bronx• Federally Qualified Health Centers (6 members) - Urban Health Plan, Morris Heights Health Center, Community Health Network, Bronx-Lebanon Integrated Service System, HELP/PSI, and Care For the Homeless. The principal FQHCs in the region. • Diagnostic and Treatment Center (1 member) - AllMed Medical & Rehabilitation, a New York City diagnostic and treatment center, operates 2 site in the PPS service area, providing open access primary and specialty care services.• Certified Home Health Agency (1 member) – Visiting Nurse Service of NYC, the largest not-for-profit home health care agency in the United States, delivers skilled nursing care, rehabilitation therapy, and behavioral health therapy for short-term care in patients’ home, as well as a wide variety of programs to support families, parents and children; family caregivers; and those at the end of life. • Mental Health Provider (1 member) - Coordinated Behavioral Care (CBC), representing over 50 NYC providers as its participating members. Together, the members offer the broad spectrum of community services needed by low income New Yorkers and populations with special needs; Targeted Case Management (TCM), DOH-licensed diagnostic and treatment centers (many of which are FQHCs and/or NCQA Level 3 medical homes), mental health clinics, chemical addiction treatment programs, supportive housing, and home care among others.• Substance Abuse Provider (1 member) – Since its inception in 1971, Narco Freedom and its affiliates have cared for thousands of addicts and their families; the current census is over 6,500 patients in treatment for alcohol and other drug addiction, and more than 30,000 patients, family members and community residents.• Skilled Nursing Facility (1 member) – Bronx-Lebanon Special Care Center, a skilled nursing facility serving long-term care AIDS and geriatric residents.

In addition, the BLHC PPS has included representatives from local stakeholders with expertise in other health and social service domains, as well as managed care organizations including:• Advance Care Alliance – Founded in 2013, Advance Care Alliance (ACA) is a collaborative of OPWDD providers in the Greater NYC region; 28 providers serve people with intellectual and developmental disabilities in the Bronx. ACA is pursuing the formation of a Developmental Disability Individual Support and Care Coordination Organization (DISCO) with EmblemHealth/HIP Health Plan.• Managed Care Plans (3 members) - Healthfirst, Affinity, and AmidaCare• NYS-designated Health Homes (2 members) - Bronx Health Home and Community Care Management Partners Health Home • Medical Group Practices (3 members) - ESSEN Medical Associates, Corinthian MedicalIPA, and Bronx United IPA • Community-Based Health as well as health and social services organizations (2 members) – FEGS, born out of the Great Depression and now one of the largest health and human services agencies in the country, providing a wide range of services and the provision of integrated, high quality, outcome-based, and cost-effective health and human services; and BronxWorks, formerly the Citizens Advice Bureau, now 40 years old, offering food, shelter, workforce development , teaching and support services throughout the Bronx.Other representatives (2 members) –1199SEIU, a union in the homecare, hospital and nursing home industries, as well as pharmacies, freestanding clinics and other healthcare settings, affiliated with the Service Employees International Union (SEIU) which is, with 2.1 million members, the largest labor Union in North America; and iHealth, a collaborative advocacy organization that represents more than 20 HIV and converted targeted case management (TCM) providers.

The BLHC PAC is investigating the addition of other representatives from relevant health and social services domains.

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

^ Any alternative proposal must be approved by the state during the DSRIP design Grant application process.

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

10.4)List all the worker representatives, union representatives and Performing Provider System partner organization representatives that will be part of the emerging Performing Provider Systems Project Advisory Committee.~ Please see instructions for clarification

(1) (2) (3) (4)

Name Partner Organization Name *Union Organization NameSam Shutman Partner Organization Representative Bronx-Lebanon Hospital Center

Alan Brand Partner Organization Representative Narco FreedomDonna Colonna Partner Organization Representative Coordinated Behavioral CareJessica Diamond Partner Organization Representative HELP/PSI

Sharon Duke Partner Organization Representative iHealthDr. Bienvenido Fajardo Partner Organization Representative Bronx United IPA

Paloma Hernandez Partner Organization Representative Urban Health PlanSarah Larson Partner Organization Representative Visiting Nurse Service of New York

Dr. Jeffrey Levine Partner Organization Representative Bronx Health HomeGlenn A. MacFarlane Partner Organization Representative Affinity

Octavio Marin Partner Organization Representative Bronx-Lebanon Special Care CenterAida Morales Union Representative 1199 SEIU

Saudah Muhammad Partner Organization Representative Bronx-Lebanon Integrated Services System, Inc.Dr. Tosiam Oruvwariye Partner Organization Representative Morris Heights Health Center

Neil Pessin Partner Organization Representative Community Care Management Partners Health Home Chris Quinones Partner Organization Representative Community Health Network

Dr. Sumir Saghal Partner Organization Representative ESSEN Medical AssociatesJay Schechtman Partner Organization Representative Healthfirst

Bob Slingsby Partner Organization Representative AllMed Medical & Rehabilitation Dr. Ramon Tallaj Partner Organization Representative Corinthian Medical IPA

Eileen Torres Partner Organization Representative BronxWorksG. Robert Watts Partner Organization Representative Care For the Homeless

Doug Wirth Partner Organization Representative AmidaCareKristin Woodlock Partner Organization Representative FEGS

Select OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect One

Partner Organization Representative/Union Representative*/Worker Representative

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

(1) (2) (3) (4)

Name Partner Organization Name *Union Organization NamePartner Organization Representative/Union

Representative*/Worker RepresentativeSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect One

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

(1) (2) (3) (4)

Name Partner Organization Name *Union Organization NamePartner Organization Representative/Union

Representative*/Worker RepresentativeSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect OneSelect One

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NYS DOH DSRIP_Project Design Grant Application Section 10 Section 10 - Project Advisory Committee (PAC)

(1) (2) (3) (4)

Name Partner Organization Name *Union Organization NamePartner Organization Representative/Union

Representative*/Worker RepresentativeSelect OneSelect OneSelect One

INDEX SCOREDomain 2 System Transformation Projects

2A. Create Integrated Delivery Systems (required)2B. Implementation of care coordination and transitional care programs2C. Connecting system

Select One2.A.I Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management 56

2.A.II Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)) 372.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. 462.A.IV Create a medical village using existing hospital infrastructure 542.A.V Create a medical village/ alternative housing using existing nursing home 42

Select One2.B.I Ambulatory ICUs 36

2.B.II Development of co-located primary care services in the emergency department (ED) 402.B.III ED care triage for at-risk populations 432.B.IV Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 432.B.V Care transitions intervention for skilled nursing facility residents 41

2.B.VI Transitional supportive housing services 472.B.VII Implementing the INTERACT project (inpatient transfer avoidance program for SNF) 41

2.B.VIII Hospital-Home Care Collaboration Solutions 452.B.IX Implementation of observational programs in hospitals 36

2.C.I Development of community-based health navigation services 372.C.II Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services 31

Select One2.A.I Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management 56

2.A.II Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)) 372.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. 462.A.IV Create a medical village using existing hospital infrastructure 542.A.V Create a medical village/ alternative housing using existing nursing home 422.B.I Ambulatory ICUs 36

2.B.II Development of co-located primary care services in the emergency department (ED) 402.B.III ED care triage for at-risk populations 432.B.IV Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 432.B.V Care transitions intervention for skilled nursing facility residents 41

2.B.VI Transitional supportive housing services 472.B.VII Implementing the INTERACT project (inpatient transfer avoidance program for SNF) 41

2.B.VIII Hospital-Home Care Collaboration Solutions 452.B.IX Implementation of observational programs in hospitals 36

2.C.I Development of community-based health navigation services 372.C.II Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services 31

Domain 3 Clinical Improvement Projects3A. Behavioral Health (Required)3B. Cardiovascular Health3C. Diabetes Care3D. Asthma3E. HIV3F. Perinatal3G. Palliative Care3H. Renal Care

Select One3.A.I Integration of primary care services and behavioral health 39

3.A.II Behavioral health community crisis stabilization services 373.A.III Implementation of evidence based medication adherence program (MAP) in community based sites for behavioral health medication compliance 293.A.IV Development of withdrawal management (ambulatory detoxification) capabilities within communities 363.A.V Behavioral Interventions Paradigm in Nursing Homes (BIPNH) 403.B.I Evidence based strategies for disease management in high risk/affected populations (adult only) 30

3.B.II Implementation of evidence-based strategies in the community to address chronic disease -- primary and secondary prevention projects (adult only) 263.C.I Evidence-based strategies for disease management in high risk/affected populations (adults only) 30

3.C.II Implementation of evidence-based strategies in the community to address chronic disease – primary and secondary prevention projects (adults only) 263.D.I Development of evidence-based medication adherence programs (MAP) in community settings –asthma medication 28

3.D.II Expansion of asthma home-based self-management program 313.D.III Evidence based medicine guidelines for asthma management 31

3.E.I Comprehensive Strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations – development of a Center of Excellence for management of HIV/AIDS 283.F.I Increase support programs for maternal & child health (including high risk pregnancies) (Example: Nurse-Family Partnership) 293.G.I IHI “Conversation Ready” model 29

3.G.II Integration of palliative care into medical homes 223.G.III Integration of palliative care into nursing homes 25

3.H.I Specialized Medical Home from Chronic Renal Failure 29

Domain 4 Population-Wide Projects4A. Promote Mental Health and Prevent Substance Abuse (MHSA)4B. Prevent Chronic Diseases4C. Prevent HIV and STD's4D. Promote Healthy Women, Infants and Children

Select One4.A.I Promote mental, emotional and behavioral (MEB) well-being in communities 23

4.A.II Prevent Substance Abuse and other Mental Emotional Behavioral Disorders 204.A.III Strengthen Mental Health and Substance Abuse Infrastructure across Systems 20

4.B.I Promote tobacco use cessation, especially among low SES populations and those with poor mental health 234.B.II Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings (Note: This project targets chronic diseases that are not included in domain 3.b., such as cancer) 174.C.I Decrease HIV morbidity 19

4.C.II Increase early access to, and retention in, HIV care 194.C.III Decrease STD morbidity 154.C.IV Decrease HIV and STD disparities 18

4.D.I Reduce premature births 24