Programs
Primary Care
Primary Care Programs
Chronic Disease Management/ Collaborative Care >
Chronic Disease Management/
Collaborative Care
Collaborative care is a multicomponent, healthcare system-level intervention.
Chronic diseases including renal, stroke, hypertension and diabetes are risk factors for heart disease. Addressing these conditions is an opportunity to reduce preventable complications, Emergency Visits and repeat hospital admissions.
Our partners identify high risk patients with hypertension and diabetes and provide evidence-based comprehensive patient-centered care, as well as behavioral health screening and referral tracking within the primary care setting. Partners provide quarterly data on key clinical metrics, identify opportunities of improvement and develop action plans.
Staten Island PPS provides transformation strategies, technical assistance, data management support and value-based incentives to improve outcomes.
In 2023
Hypertension Patients Managed
Diabetes Patients Managed
Pediatric Well Visits
Members Managed through Remote Patient Monitoring
Asthma Patients Managed
Maternal Health Program, % of Members Managed
%
90-Day Follow-up Post Partum
%
Breast Feeding
%
Depression, Intimate Partner Violence & Smoking
%
Health Navigation (CHCR Only)
Project Partners
Richmond Primary Care
