New System-Wide Care Management Program | NYC Health + Hospitals

NYC Health + Hospitals Will Adopt New System-Wide Care Management Program to Improve Health Outcomes, Address Social Determinants of Health for Patients Most at Risk of Preventable Hospitalization and Emergency Room Visits

New Model Will Target Intense Navigation Resources for Patients with Greatest Need Regardless of Insurance or Immigration Status

Feb 05, 2018

New York, NY

NYC Health + Hospitals today announced plans to adopt the first system-wide care management program designed to improve access to care and health outcomes for thousands of New Yorkers most at risk of frequent, preventable hospitalizations and emergency room visits. The new care management model will target intensive navigational resources to patients with greatest need, regardless of insurance or immigration status. The program will feature dedicated care coordinators from various disciplines who will follow a proactive outreach strategy to steer patients across the spectrum of health care services, as well as work with community partners to address social determinants of health, like housing and access to healthy food.

The new program will also feature enhanced coordinated care strategies from the ActionHealthNYC program that were particularly helpful to reach uninsured New Yorkers, including providing legal assistance, enrolling them in health insurance, and making sure they sign up for a city ID card under the IDNYC program. The new care management structure will be implemented in phases starting at NYC Health + Hospitals/Bellevue this month and is expected to be in place across the health system by the end of 2018.

The new care management initiative will serve an estimated 32,000 adult patients who have overlapping medical, behavioral health, and social needs and have more than five emergency room visits or have been hospitalized more than two times in six months or have not seen a primary care physician for more than 18 months.

“Expanding access to primary care and care management are two of my highest priorities. I am pleased that our essential health care system will be building upon the success of ActionHealthNYC by incorporating some of its strategies into our broader, system-wide care management program,” said Dr. Mitchell Katz, NYC Health + Hospitals President and Chief Executive Officer. “Through my efforts to expand access to care and coverage in San Francisco and Los Angeles, I learned that partnering with dedicated advocates to meet at-risk patients and underserved populations where they are is critical. As I begin my tenure in New York, I am looking forward to similarly successful partnerships in our shared goal of connecting more New Yorkers to the type of longitudinal care that can truly improve their health and financial security.”

“This represents a major shift in the way NYC Health + Hospitals manages care for many patients and is a significant milestone as we continue to operate increasingly like a true, city-wide system,” said Madeline Rivera, Senior Assistant Vice President for Care Management at NYC Health + Hospitals. “We will build a new care management workforce team by tapping from existing staff resources and align the work of community nurses, care managers, peer counselors, social workers, community outreach workers and other talented health care professionals across our health system to improve access to care and the health of patients most in need.”

“Make the Road New York applauds the City’s efforts to create a Care Management Program to provide more care management services to all high risk patients at NYC Health + Hospitals facilities, regardless of immigration status,” said Rebecca Telzak, Director of Health Programs at Make the Road New York. “We hope that this project builds off of lessons learned from ActionHealthNYC, and provides improved access to care and more coordinated benefits for immigrants in New York City. Through ActionHealthNYC, immigrants who were not eligible for health insurance were able to receive a primary care doctor and improved coordination of services. This was a great first step in improving access to health care for immigrants in NYC. We are excited to work with the Mayor’s office, MOIA, DOHMH and NYC Health + Hospitals to support the implementation of this new care management program.”

According to a 2017 analysis by NYC Health + Hospitals, patients at higher risk of frequent ED visits and hospitalizations had the following demographic profile:

  • More males than females
  • Majority are 25-65 years old
  • 50% black; nearly 30% Hispanic
  • Fewer than 30% are connected to primary care doctor
  • Seek care in many different facilities
  • Most are unmarried
  • Behavioral health and heart disease among most prevalent conditions
  • Housing instability among most prevalent social determinants

NYC Health + Hospitals officials have designed the new care management program based on best practices established by several population-based and value-based programs, including the Delivery System Reform Incentive Payment program, ActionHealthNYC, Health Home, Medicare Accountable Care Organization, and Project RED (re-engineered discharge).


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