Our Initiatives


Performing Provider System

Integration of Palliative Care into the Patient-Centered Medical Home (Project 3.g.i)


What do we hope to accomplish?

  • Enhance Primary Care Physicians’ competencies to integrate generalist-level palliative care in the NYP Ambulatory Care Network and community-based practices as standard of care
  • Develop a new capacity to provide specialized  palliative care services by expert team in the NYP Ambulatory Care Network
  • Develop model of care to include care management oversight and collaboration with external providers

Who is our target population?

  • Patients facing advance illnesses who have unmet palliative care needs or avoidable utilization with a diagnosis of one of six conditions: Congestive Heart Failure (CHF), Kidney Failure, Dementia, Chronic Obstructive Pulmonary Disease (COPD), Stroke, Malignancy and Sickle Cell Anemia

How will we do it?

  • Enhance Primary Care Physicians’ knowledge of palliative care for further incorporation into their practice through integrated educational interventions
  • Integrate palliative care screening and risk assessment within the NewYork-Presbyterian Hospital PPS to address unmet palliative care needs
  • Implement a specialized palliative care team to collaborate with providers throughout the PPS and provide care management services, including:
    • Employing RN Care Managers who will coordinate with other team members to conduct palliative care assessments  and provide palliative care expertise to interdisciplinary teams
    • Utilizing Community Healthcare Workers to enhance support to patient and families in the community through home visits and additional education
  • Collaborate with PPS network members to develop referral processes for palliative care

NY State Requirements

  1. Integrate Palliative Care into appropriate participating PCPs that have, or will have, achieved NCQA PCMH certification.
  2. Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice.
  3. Develop and adopt clinical guidelines agreed to by all partners including services and eligibility.
  4. Engage staff in trainings to increase role- appropriate competence in palliative care skills and protocols developed by the PPS.
  5. Engage with Medicaid Managed Care to address coverage of services.
  6. Use EHRs or other IT platforms to track all patients engaged in this project.

Scale and Speed

Metric: The number of patients receiving palliative care procedures at participating sites, as determined by the adopted clinical guidelines.

Commitment: At the completion of Year 2, the Palliative Care Project will provide palliative care procedures to 2,565 unique patients annually.