Programs & Initiatives

Continuity of Care

SOMOS network providers across New York City see over 25,000 primary and specialty patients per day on average from prenatal through senior care.

SOMOS network providers continue to provide exceptional, quality-based care to the person as a whole, continuing to provide mental health and behavioral health screenings and interventions, care coordination and assistance with addressing SDOH through community connections, etc.

SOMOS is the only one of the original 25 PPSs that continues charting and applying the value-based-payment model even after the cessation of DSRIP, by developing and applying cost-saving and life-saving innovations.

Research and Data Efforts Speaking to Population Health

SOMOS designed and commissioned:

Multi-year communications efforts based on participatory research conducted and related data culled from community needs assessments and SOMOS’ Invisible: State of Latino Health and MisUnderstood: State of Chinese Health studies.
Branding to spur community trust: SOMOS designed and implemented branding and messaging in alignment with the stated needs of communities served. These efforts included direct patient engagement in targeted areas through multimedia, health fairs and community collaboration encouraging access to neighborhood-based primary care.

Further Innovation in Cutting-Edge Care

Stewarding value-based care to our SOMOS network providers through ancillary support and facilitation to amplify value-based care goals.
Maintaining patient-centeredness in all of SOMOS network provider’s care.
Maintains over 1,000 SOMOS network providers to manage and monitor their patient’s medical information and treatment via RHIO and Electronic Medical Records (EMR) access.
Expanding telemedicine capabilities for SOMOS network providers.
Working actively with SOMOS network providers to close care gaps.
Tackling the Behavioral Health crisis by working with SOMOS network providers to widely engage in screening patients using instruments such as the Patient Health Questionnaire-9 (PHQ-9) during visits at the SOMOS network provider’s offices.
Working with patients to ensure they continue to receive the Medicaid benefits to which they are entitled.

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