Projects 2018-01-23T15:28:40+00:00
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NQP selected 11 projects from a list of 44 options offered by the state that align with the results of our Community Needs Assessments.

The projects we have selected vary widely and include population-wide projects, such as reducing tobacco use, and system transformation projects, such as creating an integrated delivery system.

Health care is moving from the fee for service model to a value-based payment, where providers will be reimbursed based off of the value they provide to patients rather than their volume of patients. By recognizing and adapting to this change, we will play an enhanced and rewarding role in improving the health of our community. Our objective is to achieve system transformation by working collaboratively with our partners to create a delivery system that is truly patient-centered. The effective and timely implementation of the DSRIP projects is vital to the success of participating providers.

A comprehensive community health needs assessment has shown that we need to:

  • Improve care for residents with mental health, substance abuse, cardiovascular disease, or diabetes
  • Improve care for low-income communities, especially in Southwest and West Central Nassau County
  • Provide care that is culturally relevant to our community
  • Provide more coordinated care across various health care settings

View Community Needs Assessment

Domain 2

System Transformation

2.a.i – Create an Integrated Delivery System focused on Evidence-Based Medicine and Population Health Management

Objective: Creating an integrated delivery system focused on evidence-based care for at-risk populations, specifically those with behavioral health challenges and chronic illnesses.

Application Details


2.b.ii – Development of Co-Located Primary Care Services in the Emergency Department

Objective: To improve access to primary care services with a PCMH model co-located/adjacent to community emergency services.

Application Details


2.b.iv – Care Transitions Intervention Model

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

Application Details


2.b.vii – Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for Skilled Nursing Facility (SNF))

Objective: INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program focused on the management of changes in a SNF resident’s condition, with the goal of stabilizing the patient and avoiding transfer to an acute care facility.

Application Details


2.d.i – Patient Activation Activities

Objective: To engage, educate, and integrate the uninsured and the non- and low-utilizing Medicaid populations into community-based care. This project aims to increase patient activation related to health care by pairing efforts with increased resources to help patients gain access to and use the benefits associated with NQP projects, particularly primary and preventive services.

Application Details

Domain 3

Clinical Improvement

3.a.i – Integration of primary care and behavioral health

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

Application Details


3.a.ii – Behavioral health community crisis stabilization services

Objective: To provide readily accessible behavioral health crisis services that will allow access to appropriate level of service and providers, supporting a rapid de-escalation of the crisis.

Application Details


3.b.i – Evidence based strategies for disease management in high risk/affected populations (adults only) – Cardiovascular Health

Objective: To support implementation of evidence-based best practices for disease management in medical practice for adults with cardiovascular conditions.

Application Details


3.c.i – Evidence based strategies for disease management in high risk/affected populations (adults only) – Diabetes

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

Application Details

Domain 4

Population Wide

4.a.iii – Strengthen Mental Health and Substance Abuse Infrastructure across Systems

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

Application Details


4.b.i – Promote tobacco use cessation

Objective: This project will promote tobacco use cessation, especially among low SES populations and those with poor mental health.

Application Details