Project to Address the Socioeconomic Needs of Primary Care Patients


In the first two years of the New York City PHIP, the Advanced Primary Care Group uncovered five major issues related to the delivery of primary care in NYC and developed a set of recommendations for addressing them. The PHIP then advanced one of these recommendations by identifying a shared-services business model that can help small, independent primary care practices – who represent 40% of the primary care workforce in NYC – survive the healthcare industry’s transition to value-based payment financing.


Project Overview


Recognizing the need for tools that will enable primary care practices located in under-resourced communities to thrive in value-based payment arrangements, the United Hospital Fund (UHF) is now leading the development of a “Blueprint for Primary Care/Community Partnerships.” This work intends to support practices that serve a large number of individuals who are at risk of adverse health outcomes due to socioeconomic factors (unstable housing, food insecurity, etc). Addressing these factors, which are often referred to as a patient’s “social determinants of health” (SDH), requires robust clinical-community partnerships in which primary care practices identify risks and work with external partners (e.g. community-based organizations such as social service agencies) to connect patients and families to enhanced services and supports.


In 2018 UHF is working closely with federally qualified health centers in two high-priority communities to develop, vet, and pilot a process for creating effective clinical/community partnerships that facilitate: 1) screening for social determinants of health; 2) referral to appropriate health and social services; and, 3) feedback loops between social service organizations and primary care providers to encourage effective follow-up. The lessons from this work will be compiled in a “Blueprint for Primary Care / Community Partnerships” designed to encourage spread of the model.


The PHIP Small Practice Project Report

The report is intended to help small primary care providers and their potential partners understand the economics of shared-service arrangements. It describes a business model in which small practices can share the cost of needed services—such as care managers, diabetes educators, and health information technology staff— that can enable them to better care for their patients as medical homes, and reduce preventable hospital admissions and visits to emergency departments. These new capacities can also help small practices to participate effectively in value-based payment arrangements that reward quality and efficiency instead of the volume of services provided.


A Strategy for Expanding and Improving the Impact of the Medical Home Across New York City

This report, authored by the NYC Department of Health and Mental Hygiene and United Hospital Fund, is a roadmap of five strategies aimed at expanding and improving the impact of the medical home model of primary care across New York City. The report is intended to guide New York City’s primary care providers, as well as health plans, policymakers, and other stakeholders, in the adoption of a delivery model that improves health care quality, improves patients’ experience of care, and reduces avoidable emergency department visits and hospital admissions.


Chad Shearer

Vice President for Policy

United Hospital Fund



Gregory Burke

Director, Innovation Strategies

United Hospital Fund