Institute for Family Health PCMH Program

Program Location: 
Bronx, NY
Number of Practices: 
Payer Type: 
New York State Medicaid

Reported Outcomes


The Institute for Family Health (the Institute) is a network of Federally Qualified Health Centers located throughout New York State, reaching from lower Manhattan in New York City to Ulster County in the Hudson Valley. The network began a process of practice redesign in 2002 with the implementation of an electronic health record (EHR). Additional practice innovations were implemented in the subsequent 9-year period. The Institute achieved Level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA) in 2009, and again in 2012 with the enhanced standards across its network of 17 sites. All sites are located in medically underserved areas, and sites range in size from 2 primary care clinicians (2 urban practices and 1 rural practice) to more than 20 such clinicians (2 urban practices) with most practices having between 4 and 8. All practices operate on a family medicine model, and the vast majority of primary care clinicians are trained in family medicine. All practices have on-site psychosocial services that range from a social worker in smaller sites to fully licensed outpatient mental health facilities in several larger sites. Four sites have dental services. Two of the sites are primary teaching facilities for community-based family medicine residency program, and all sites provide clinical training for students from a variety of health professions schools.

A set of PCMH practice changes specifically focused on the care of patients with diabetes. These changes included the following:

  • Group visits in English and Spanish to promote patient education and peer support (2007);
  • Appointment of a family physician as the Diabetes Medical Director, responsible for overseeing activities at all sites related to the care of patients with diabetes and prediabetes (2008);
  • Creation of a diabetes registry and a quality reporting tool
  • Addition of certified diabetes educators (CDEs) to the care team (2008), an effort supported by a private foundation grant;
  • Implementation of EHR-based clinical decision supports for each NCQA diabetes measure (2008);
Improved Health: 
  • Reduction in mean annual A1c levels from approximately 10.72% to 8.34%
Improved Access: 
  • Increase in access to psychosocial, diabetes education, and primary care services by diabetes patients
Increased Preventive Services: 
  • Increase in patient outreach services, diabetes education support, and HbA1c monitoring and testing
Last updated September 2014
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