The state has been transitioning to a new model of care for Medicaid patients focused on preventing illness, but it takes a team appraoch that not every doctor can afford. Health Reporter Erin Billups takes a look at group of doctors that have joined forces to offer better care.

When Dr. A.T. Adebayo started his Harlem-based practice 20 years ago, primary care doctors were considered the gatekeepers of their patients' health. But he says that eroded overtime.

"The challenges, one were that patients were going all over the place. They see more specialists, there's no coordination of care per se. They end up in the hospital mostly," he recalls.

Driving down unnecessary emergency room visits 25 percent by 2020 is the goal of ongoing state Medicaid reforms.

Doctors and hospitals are now rewarded for coordinating a patient's care - reimbursed for patients overall care, instead of each individual service they provide.

In order to offer that level of care, Adebayo joined a group of more than 2,000 other independent physicians called Advocate Community Providers or ACP.

"These doctors were providing care but struggling, they didn't have the resources to support them, that doctors who might be employed by a hospital would have," says Advocate Community Providers COO Mary Ellen Connington.

By pooling resources they've gained access to more than $700 million in state funding, allowing them to update their services in low-income communities.

Now ACP's 650,000 patients in Manhattan, Queens, Brooklyn and the Bronx can connect to their doctor and records through an online portal. There are also community health workers that follow up with patients, walking them through changes in their care and connecting them to specialists when needed.

"For us it is a necessity, it is a survival. We have to do this in order to continue to shore up that community based provider network in the communities we serve," says Connington.

"The coordination with ACP has really helped to improve the level of service we provide to the community," says Adebayo.

Adebayo's patient Zola Ivery has noticed the difference. The coordinated care is helping her to control her asthma and lose weight.

"We're patients, you know we're humans. You get better care from your doctor because he's looking at you as a whole patient," she says.

The state Health Department says even with a looming repeal to Obamacare it intends to keep the program going.