Primary Care

Primary Care Programs

Chronic Disease Management/ Collaborative Care >

HealthFirst Navigation

Fair Start Program

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