DSRIP Program

What is DSRIP?

First things first – “DSRIP” stands for Delivery System Reform Incentive Payment program.

It is a five-year program overseen by the New York State Department of Health (DOH) and the Centers for Medicare and Medicaid Services (CMS) to fundamentally reform how health care is delivered to New York’s Medicaid population. DSRIP’s primary goal is to reduce preventable hospital and emergency department readmissions by 25 percent in five years, relying on increased access to integrated mental health and primary care services and other preventive health programs offered in the outpatient setting.

To make this change happen, New York has called on its hospitals, private practices and other health care and community-based organizations to work together as “Performing Provider Systems” (PPS). Each of the 25 PPS across the state will receive a share of more than $6.4 billion based on its ability to meet key performance metrics. This turns the current health care delivery model upside-down, reimbursing hospitals and physicians for the quality of care they provide rather than the quantity of patients they serve.



In northern New York, the North Country Initiative serves as the lead DSRIP applicant for providers and organizations across Jefferson, Lewis and St. Lawrence counties. Our PPS consists of more than 500 providers, facilities and community-based organizations, as well as six hospitals throughout the tri-county region.

Together, we have chosen 11 projects that reflect the unique health care needs of our community, and we collaborate with our partners every day to ensure all project milestones are met on time. In the first year of DSRIP, our partners met every project milestone, earning 100 percent of DSRIP funding available to them.

Details of our region’s 11 DSRIP projects can be found below, or by watching our short “DSRIP 101” video:

Creating an Integrated Delivery System (2.a.i)

This project calls on all of our partners to work together to develop and maintain initiatives that improve the health of the community as a whole. It requires medical, behavioral health, post-acute, long term care and social service entities – as well as payers – to collaborate and transform our competitive, institutionally-based delivery system to a community-based one. If successful, this project will eliminate duplicate and fragmented health care services, saving time and money.

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Transforming Primary Care Offices with the Patient Centered Medical Home Model (2.a.ii)

A key requirement of health care transformation is the availability of high-quality primary care for all Medicaid recipients and uninsured, including children and patients with higher risks. This project allows certain providers to undergo a rapid transformation by adopting the Patient Centered Medical Home (PCMH) model – a nationally-recognized model for care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.”

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Creating a Medical Village with Existing Hospital Infrastructure (2.a.iv)

This project will convert outdated or unneeded hospital spaces into standalone emergency departments/urgent care centers. This reconfiguration, referred to as a “medical village,” will allow for the new space to be utilized as the center of a neighborhood’s coordinated health network, supporting service integration and providing a platform for primary care and behavioral health integration. If successful, the proposed medical villages will be seen and used by the community as a “one-stop-shops” for health and health care.

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Using Care Transition Protocols to Reduce Hospital Readmissions (2.b.iv)

A majority of hospital readmissions occur because a patient does not understand or chooses not to comply with instructions given to them when they are discharged. To help counteract this, project 2.b.iv encourages hospitals to utilize transition case managers – qualified team members who work one-on-one with at-risk patients to provide them with pre-discharge education, community-based support and other services to keep them healthy after their release from the hospital or emergency room.

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Engaging and Educating the Medicaid Population (2.d.i)

This project seeks to engage and activate community members who are not utilizing the health care system and encourage those individuals to utilize local primary and preventive care services. Engaging this population can prevent future emergency department and inpatient utilization and prevent future onset of chronic disease.

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Integrating Primary Care and Behavioral Health (3.a.i)

Providing primary care and behavioral health care services under the same roof can help providers to identify behavioral health diagnoses early, ensure treatments for medical and behavioral health conditions are compatible and do not cause adverse effects, and de-stigmatize treatment for behavioral health diagnoses. This project aims to achieve these goals by placing behavioral health specialists in primary care clinics, adding primary care services to established behavioral health sites and through alternative models.

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Using Evidence-Based Care to Manage Cardiovascular Disease (3.b.i)

As the title suggests, this project calls for providers to use evidence-based – or “best practice” – treatment guidelines to help adults with cardiovascular disease manage their chronic condition in the outpatient setting.

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Using Evidence-Based Care to Manage Diabetes (3.c.i)

Much like project 3.b.i, this project ensures that clinical practices in the community and ambulatory care setting use evidence-based strategies to help adults manage their diabetes.

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Creating Community Resources for Chronic Disease Management (3.c.ii)

While Project 3.c.i is focused on diabetes care practice improvement, this project focuses on developing community resources to assist patients in adopting preventive strategies to reduce risk factors for diabetes and ameliorate the long-term consequences of diabetes and other co-occurring chronic diseases.

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Strengthening Mental Health and Substance Abuse Resources (4.a.iii)

This project will support collaboration among leaders, professionals, and community members working in mental, emotional and behavioral health promotion to address substance abuse and other mental health disorders. Because mental, emotional and behavioral health promotion and disorders prevention is a relatively new field, work under this project will require a paradigm shift in approach and perspective.

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Increasing Access to Preventive Care in Clinical and Community Settings (4.b.ii)

This project aims to increase the number of north country residents who receive evidence-based preventive care and management for chronic diseases by increasing access to screening tests, counseling, immunizations or medications used to prevent disease and other services. High-quality preventive care and chronic disease management can prevent much of the burden of chronic disease and save money.

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