Primary Care

Project Title

Health Care in Housing: An Integrated Care Model to Improve Racial Disparities in Primary Care Engagement

Grant Amount


Priority Area

Primary Care

Date Awarded

November 13, 2023




In Progress


Primary care is often a patient’s first and most regular point of contact with the health care system.

High-quality primary care provides ongoing, relationship-based care that meets the health needs and preferences of individuals, families, and communities, according to the National Academies of Sciences, Engineering, and Medicine. It is a rare “win-win” in health care that improves individual and community health, enhances health equity, and saves money. Despite the benefits, too little is invested in primary care and too many New Yorkers, especially New Yorkers of color, have difficulty getting care when and where they need it. In 2023, NYHealth issued a Request for Proposals (RFP), “Primary Care: Expanding Access and Advancing Racial Health Equity,” to test replicable models to improve the accessibility, quality, and equity of primary care in regions across the State. NYHealth awarded EngageWell IPA a grant to participate in this initiative.  

Under this grant, EngageWell will connect residents living in emergency shelters and supportive housing across New York City to virtual medical and behavioral health services, aiming to reduce racial health disparities in primary care use and health management. EngageWell will facilitate a planning process with input from shelter and supportive housing residents to create a virtual, trauma-informed medical care experience that increases access to and trust in routine preventive care. EngageWell will seek to provide residents with 700 virtual primary care, urgent care, and mental health visits in home and congregate settings at up to 7 housing agencies. Residents will receive support and technology navigation from community health workers and referrals to follow-up care with EngageWell’s health care provider network. EngageWell will prioritize care to residents of color, residents with chronic conditions, residents who have not seen a primary care doctor in the past year, and residents who frequent the emergency department. EngageWell will evaluate the impact of this model on reducing emergency department use and share project findings through fact sheets, policy briefs, or conference presentations. It will disseminate best practices and lessons learned to stakeholders including national and statewide housing and health care provider networks; university partners; and digital health vendors.  

See a full list of grantees working to expand access to and advance racial health equity in primary care across New York State.