SOMOS Community Care’s mission is to serve community doctors and providers with the support necessary to drive high-quality, patient-centered care in NYC’s most vulnerable communities.
We are changing the culture of health care from reactive to proactive, so our communities can take control of their health through accessible, and culturally-competent primary care.
SYSTEM TRANSFORMATION PROJECTS
Integrated Delivery System
SOMOS is creating an integrated system that will enable primary care providers (PCPs) and specialists to better coordinate services and improve patient outcomes.
Health Home At-Risk Intervention
Comprehensive care plans have been developed for patients with a progressive chronic disease, serious mental illness, or traumatic brain injury who are at risk of developing another due to medical and social factors.
ED Care Triage for At-Risk Populations
Linkages are being created between hospital emergency departments (ED) and PCPs so that a follow-up appointment is scheduled with the PCP when a patient visits the emergency room.
Care Transitions to Reduce 30-Day Readmissions
SOMOS is connecting hospitals to PCPs so that every patient with a hospital admission is scheduled for an appointment with his or her PCP within 7–10 days in order to avoid 30-day readmission.
CLINICAL IMPROVEMENT PROJECTS
Integration of Primary Care and Behavioral Health
SOMOS is integrating the IMPACT model into primary care by training In-Practice Depression Care Managers to provide education and support to mental health and substance abuse patients.
Implementing evidence-based best practices for adults with cardiovascular conditions.
Promoting evidence-based strategies to improve diabetes management.
Ensuring access for all patients with asthma to care that is consistent with evidence-based guidelines for self-management of asthma.
Tobacco Use Cessation
Decreasing the prevalence of cigarette smoking in adults by promoting counseling in medical offices and facilitating referrals to the NYS Smokers’ Quitline.
Chronic Disease Prevention
Increasing the number of patients who receive evidence-based preventive care, including screening tests and vaccinations.
- Create an integrated delivery system to transform delivery of health care in New York City.
- Increase access to primary care and specialty services to narrow gaps in care and reduce healthcare disparities.
- Collaborate with community-based providers and stakeholders to identify and address the needs of the patient.
- Promote disease prevention and population health measures to reduce avoidable hospital visits by 25%.
- Promote evidence-based medicine protocols that are patient-centric.
- Incorporate health information technology to foster enhanced communication between healthcare providers.
- Improve the quality of care and achieve savings for the New York State Medicaid Program.