Transforming Care Delivery in New York’s Poorest County

Categories: Capacity Building

A group of more than 230 Bronx organizations known as the Bronx Partners for Healthy Communities (BPHC) has taken collective action on their community’s health — and PCDC has been a driving factor in their success.

Led by St. Barnabas Hospital as part of New York State’s Delivery System Reform Incentive Payment (DSRIP) Program, BPHC is forging ahead to ensure every resident of this borough receives comprehensive and coordinated care.

In the early stages of the DSRIP Program, BPHC conducted a community needs assessment to identify health, social, and economic issues and challenges facing the Bronx. The findings were stark: Bronx County is the poorest in New York State with 30 percent poverty and 12 percent unemployment rates, and consequently has some of the state’s greatest health disparities. At the same time, the Bronx is a vibrant urban community well-positioned to improve its circumstances.

Based on their findings, BPHC and Primary Care Development Corporation (PCDC) partnered to develop a comprehensive training program. The objective was to prepare health care workers with the skills for providing person-centered care coordination to patients with the most complex health and social needs.

Since the partnership began in early 2016, PCDC has completed five cohorts of the seven-day comprehensive Care Coordination Training program, reaching more than 150 health care workers representing over 40 organizations. A sixth cohort is scheduled to begin this month.

Angela Fernandez and Yael Lipton, both Training and Curriculum Development Specialists in PCDC’s Capacity Building group, work closely with BPHC to shape the curriculum, ensuring it continues to meet the specific needs of the community. The care coordination curriculum covers topics including chronic conditions, social determinants of health, values and bias, and medication management.

PCDC trainers reinforce each topic throughout the training series, emphasizing the goal of person-centered care — which accounts for patients’ personal preferences and values — and the relationship of environmental and economic factors to health. Trainers draw on each participant’s personal experiences as a patient, caregiver, or health care worker to further enhance the training experience.

Because Fernandez and Lipton also teach the training sessions and have built relationships with the staff and participants, they are able to identify additional workforce training needs. Over the last two years, they have added training topics specific to the BPHC staff such as trauma and health literacy, in which Fernandez and Lipton are experts, respectively.

This personal touch has been invaluable in meeting the needs not just of BPHC as an organization, but of each distinct cohort that moves through the comprehensive Care Coordination Training program, according to staff.

“PCDC has proven to be an integral part of the way we train our care coordination staff,” said Mary Morris, Director of Workforce Innovation at Bronx Partners for Healthy Communities. “From curriculum design to executing lessons, Angie and Yael’s care and dedication have made them a pleasure to work with and learn from. We at BPHC are thrilled that this partnership has been so successful.”

The BPHC care coordination curriculum was developed as part of PCDC’s Care Management Training program. Our original Care Coordination Fundamentals course, developed in partnership with 1199 SEIU Training and Employment Funds, has been taught to thousands of participants. PCDC has enhanced this curriculum and is able to customize this program to meet the unique needs of staff working in a range of transformation initiatives including Patient-Centered Medical Home (PCMH), Health Homes, and Delivery System Reform Incentive Programs (DSRIP), among others.

For more information or to request training services, please visit our Capacity Building website, call 212-437-3926, or email