CCB utilized DSRIP funding to further leverage clinical and technological infrastructure to establish an integrated system of care across a broad range of medical, behavioral and social sectors and to improve care coordination and communication among providers throughout the borough and enhance population health management for the most complex patients.

• Serving as the largest PPS in Brooklyn for the duration of DSRIP, with a scalable governance model and 4,600 physicians, including 1,600 primary care doctors, and 650,000 attributed patients
• Expanding the reach of the Department of Population Health and clinical and transitional care programs at Maimonides
• Providing technical assistance for 138 primary care sites and 400 PCPs to achieve PCMH recognition
• Reducing avoidable hospitalizations by 30%+ over 5-year period
• Implementing programming to improve patients’ quality of care in palliative care, asthma, and cardiovascular disease
• Reducing ED and inpatient utilization through the implementation of transitional care teams
• Engaging the healthcare workforce by training over 1,500 staff from 156 organizations in over 50,000 hours of training.
• Studying and addressing social determinants of health in Brooklyn with over 170 students conducting participatory action research, with findings that resulted in the creation of fitness and education programs and a hydroponic farm, in addition to other community programs
• Helping partners access tens of millions in Capital Restructuring Financing Program funds for critical projects
• Generating revenues of more than $336 million for reinvestment in Brooklyn
• Supporting provider network’s transition to value-based contracting

CCB’s work continues through a number of organizations managed through the Maimonides Department of Population Health.
Brooklyn Communities Collaborative
Community Care of Brooklyn IPA
The Brooklyn Health Home