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The Brooklyn PHIT project is a part of the NYS Medicaid Redesign Team (MRT) Health Information Technology (HIT) Initiative with demonstration projects in 3 regions of the state including this Downstate project. The initiative’s goal is to demonstrate effective use of HIT to improve care coordination and enhance service quality and delivery between medical care providers and social health/human services community based organizations (CBOs). The prime focus of the initiative is the early identification of pregnant/postpartum women who may be at high risk for poor perinatal outcomes due to medical or social factors. By assuring timely access to coordinated services and other resources, we hope to mitigate identified risks and improve health outcomes for mom and baby.

True care coordination for effective continuity of care requires:

1. Appropriate and timely referrals for complementary support services based on risk factors in addition to medical care
2. Feedback to the referring provider about the disposition of the referral
3. Shared information with all organizations serving the individual client

Improved care delivery is achieved through utilizing the PeerPlace web enabled health information technology system aimed at improving efficiency of referrals amongst participating organizations through simple eligibility screening, risks/needs assessments and identification of appropriate program options.

The system offers:

1. A web-based, HIPAA compliant software solution to facilitate continuity of care across health and human service providers
2. A standardized perinatal risk assessment form (PRF) for participating human service and clinical providers that allows for immediate access to important client information when receiving a referral and improves the quality of their care delivery and content
3. A growing network of community based human and health service providers
4. A referral pathway to service providers not participating in the BPHIT Network
5. An optional enhanced case management module that works in conjunction with the screening and referral features
6. Access to Public Web Portal containing standardized perinatal risk assessment form (PRF) for use by providers and clients wanting to be connected to community based services

Network Partners include:

CAMBA, Caribbean Women’s Health Association, Christopher Rose Community Empowerment Campaign, Diaspora Community Services, Fort Greene Strategic Neighborhood Action Partnership

We welcome new opportunities for partnership. To learn more about joining the BPHIT Network or accessing the Perinatal Screening Public Portal please email This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

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