Region: NYC

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. Patients of color can face unique obstacles, including racism, bias, mistrust, and gaps in communication between patients and physicians. Engaging patients of color is an important step toward the development of a more equitable health system; however, few reliable metrics that capture patients’ perceptions of health equity exist.

The SUNY Downstate Health Sciences University (DHSU), in collaboration with partners One Brooklyn Health System and Arthur Ashe Institute for Urban Health, developed a patient-centered index to measure and address racial inequities in patient experience, grounded in the experiences of people living in Central Brooklyn, called the Brooklyn Health Equity Index (BKHI). BKHI is a 10-item health equity metric developed throughout a two-year community-engaged research project that amplifies patients’ voices and perceptions of inequities. 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 the Research Foundation for the State University of New York (SUNY), on behalf of DHSU, a grant to participate in this initiative and scale the Brooklyn Health Equity Index to multiple health systems in Central Brooklyn.

Under this grant, DHSU and partners will implement BKHI in numerous clinics (including primary care) at University Hospital at Downstate and One Brooklyn Health System; use findings to drive patient experience improvement initiatives; and measure associations between BKHI scores and health care use and outcomes. BKHI findings will drive transformation at the patient-provider level by capturing information on patient experiences within the domains of trust, discrimination/disrespect, and provider acknowledgment of social determinants of health, and at the system level by providing an aggregate measure of health equity. The long-term goal is to evaluate the impact of routine health care system use of BKHI on patient experience; support health systems in making progress toward health equity; and spread BKHI use to health systems across New York State.

Policy changes, broader restrictions, and looming Medicaid cuts have deterred many New Yorkers from seeking essential care, increasing the likelihood that preventable conditions worsen. Primary care providers have reported a drop-off in patients seeking services. NYC Care, a citywide health care access program, expanded its outreach to ensure new and existing patients know about NYC Care as an affordable, safe option. However, persistent digital and logistical barriers continue to limit patient access to preventive and primary care. During the COVID-19 pandemic, NYHealth supported NYC H+H to launch a telehealth patient navigation program that provided one-on-one support before and after visits, improving participation and patient satisfaction. That initiative strengthened the health system’s capacity and laid out the groundwork for sustained equitable access to virtual care. In 2025, NYHealth awarded NYC H+H a grant to expand equitable access to in-person and virtual primary care for underserved New Yorkers.

Under this grant, NYC H+H will implement a culturally and linguistically responsive patient navigation initiative to help patients enroll in and engage with NYC Care. The initiative will be implemented across four NYC H+H sites, reaching an estimated 6,000 patients. Multilingual patient navigators will provide in-person and remote support to help patients enroll in NYC Care, prepare for and attend primary care visits, and engage in ongoing care through personalized education, reminders, and digital assistance. Through culturally responsive navigation before and after visits, NYC Care aims to strengthen patient engagement, reduce missed appointments, and use insights from navigator activities to improve retention and scale effective strategies over time.